An alternative estimation of the death toll of the Covid-19 pandemic in India.

The absence of reliable registration of Covid-19 deaths in India has prevented proper assessment and monitoring of the coronavirus pandemic. In addition, India's relatively young age structure tends to conceal the severity of Covid-19 mortality, which is concentrated in older age groups. In this paper, we present four different demographic samples of Indian populations for which we have information on both their demographic structures and death outcomes. We show that we can model the age distribution of Covid-19 mortality in India and use this modeling to estimate Covid-19 mortality in the country. Our findings point to a death toll of approximately 3.2-3.7 million persons by early November 2021. Once India's age structure is factored in, these figures correspond to one of the most severe cases of Covid-19 mortality in the world. India has recorded after February 2021 the second outbreak of coronavirus that has affected the entire country. The accuracy of official statistics of Covid-19 mortality has been questioned, and the real number of Covid-19 deaths is thought to be several times higher than reported. In this paper, we assembled four independent population samples to model and estimate the level of Covid-19 mortality in India. We first used a population sample with the age and sex of Covid-19 victims to develop a Gompertz model of Covid-19 mortality in India. We applied and adjusted this mortality model on two other national population samples after factoring in the demographic characteristics of these samples. We finally derive from these samples the most reasonable estimate of Covid-19 mortality level in India and confirm this result using a fourth population sample. Our findings point to a death toll of about 3.2-3.7 million persons by late May 2021. This is by far the largest number of Covid-19 deaths in the world. Once standardized for age and sex structure, India's Covid-19 mortality rate is above Brazil and the USA. Our analysis shows that existing population samples allow an alternative estimation of deaths due to Covid-19 in India. The results imply that only one out of 7-8 deaths appear to have been recorded as a Covid-19 death in India. The estimates also point to a very high Covid-19 mortality rate, which is even higher after age and sex standardization. The magnitude of the pandemic in India requires immediate attention. In the absence of effective remedies, this calls for a strong response based on a combination of non-pharmaceutical interventions and the scale-up of vaccination to make them accessible to all, with an improved surveillance system to monitor the progression of the pandemic and its spread across India's regions and social groups.

Projecting sex imbalances at birth at global, regional and national levels from 2021 to 2100: scenario-based Bayesian probabilistic projections of the sex ratio at birth and missing female births based on 3.26 billion birth records.

INTRODUCTION: Skewed levels of the sex ratio at birth (SRB) due to sex-selective abortions have been observed in several countries since the 1970s. They will lead to long-term sex imbalances in more than one-third of the world's population with yet unknown social and economic impacts on affected countries. Understanding the potential evolution of sex imbalances at birth is therefore essential for anticipating and planning for changing sex structures across the world. METHODS: We produced probabilistic SRB projections from 2021 to 2100 based on different scenarios of sex ratio transition and assessed their implications in terms of missing female births at global, regional and national levels. Based on a comprehensive SRB database with 3.26 billion birth records, we project the skewed SRB and missing female births with a Bayesian hierarchical time series mixture model. The SRB projections under reference scenario S1 assumed SRB transitions only for countries with strong statistical evidence of SRB inflation, and the more extreme scenario S2 assumed a sex ratio transition for countries at risk of SRB inflation but with no or limited evidence of ongoing inflation. RESULTS: Under scenario S1, we projected 5.7 (95% uncertainty interval (1.2; 15.3)) million additional missing female births to occur by 2100. Countries affected will be those already affected in the past by imbalanced SRB, such as China and India. If all countries at risk of SRB inflation experience a sex ratio transition as in scenario S2, the projected missing female births increase to 22.1 (12.2; 39.8) million with a sizeable contribution of sub-Saharan Africa. CONCLUSION: The scenario-based projections provide important illustrations of the potential burden of future prenatal sex discrimination and the need to monitor SRBs in countries with son preference. Policy planning will be needed in the years to come to minimise future prenatal sex discrimination and its impact on social structures.

Sex ratio at birth in Vietnam among six subnational regions during 1980-2050, estimation and probabilistic projection using a Bayesian hierarchical time series model with 2.9 million birth records.

The sex ratio at birth (SRB, i.e., the ratio of male to female births) in Vietnam has been imbalanced since the 2000s. Previous studies have revealed a rapid increase in the SRB over the past 15 years and the presence of important variations across regions. More recent studies suggested that the nation's SRB may have plateaued during the 2010s. Given the lack of exhaustive birth registration data in Vietnam, it is necessary to estimate and project levels and trends in the regional SRBs in Vietnam based on a reproducible statistical approach. We compiled an extensive database on regional Vietnam SRBs based on all publicly available surveys and censuses and used a Bayesian hierarchical time series mixture model to estimate and project SRB in Vietnam by region from 1980 to 2050. The Bayesian model incorporates the uncertainties from the observations and year-by-year natural fluctuation. It includes a binary parameter to detect the existence of sex ratio transitions among Vietnamese regions. Furthermore, we model the SRB imbalance using a trapezoid function to capture the increase, stagnation, and decrease of the sex ratio transition by Vietnamese regions. The model results show that four out of six Vietnamese regions, namely, Northern Midlands and Mountain Areas, Northern Central and Central Coastal Areas, Red River Delta, and South East, have existing sex imbalances at birth. The rise in SRB in the Red River Delta was the fastest, as it took only 12 years and was more pronounced, with the SRB reaching the local maximum of 1.146 with a 95% credible interval (1.129, 1.163) in 2013. The model projections suggest that the current decade will record a sustained decline in sex imbalances at birth, and the SRB should be back to the national SRB baseline level of 1.06 in all regions by the mid-2030s.

Probabilistic projection of the sex ratio at birth and missing female births by State and Union Territory in India.

The sex ratio at birth (SRB) in India has been reported to be imbalanced since the 1970s. Previous studies have shown there is a great variation in the SRB between geographic locations across India till 2016. Considering the enormous population and regional heterogeneity of India, producing probabilistic SRB projections at the state level is crucial for policy planning and population projection. In this paper, we implement a Bayesian hierarchical time series model to project the SRB across India by state. We generate SRB probabilistic projections from 2017 to 2030 for 29 States and Union Territories (UTs) in India, and present results for 21 States/UTs with data available from the Sample Registration System. Our analysis takes into account two state-specific factors that contribute to sex-selective abortion in India, resulting in sex imbalances at birth: the intensity of son preference and fertility squeeze. We project that the highest deficits in female births will occur in Uttar Pradesh, with a cumulative number of missing female births of 2.0 (95% credible interval [1.9; 2.2]) million from 2017 to 2030. The total female birth deficits during 2017-2030 for the whole of India is projected to be 6.8 [6.6; 7.0] million.

On the estimation of female births missing due to prenatal sex selection.

This research note is prompted by a paper by Kashyap (Is prenatal sex selection associated with lower female child mortality? Population Studies 73(1): 57-78). Kashyap's paper, which provides 40 original estimates of missing female births, relies on an alternative definition of missing female births, leading to estimates of about half the magnitude of other estimates. There appears, therefore, a real need to take stock of the concept of missing female births widely used by statisticians around the world for assessing the demographic consequences of prenatal sex selection. This research note starts with a brief review of the history of the concept and the difference between Amartya Sen's original method and the alternative method found elsewhere to compute missing female births. We then put forward three different arguments (deterministic and probabilistic approaches, and consistency analysis) in support of the original computation procedure based on the number of observed male births and the expected sex ratio at birth.

Skewed sex ratios at birth: A review of global trends.

Several cultures in the world traditionally favor the birth of sons over that of daughters. This preference drives various forms of discrimination against female births ultimately reflected in demographic imbalances. Over the last decades, modern reproductive technology has made prenatal diagnosis widely accessible to parents. In certain Asian and Eastern European countries, this has led to skewed sex ratio at birth (SRB) as a result of sex-selective abortions. After reviewing motivations and circumstances associated to prenatal sex selection, our paper analyzes global trends in sex imbalances at birth as well as their parity, regional and socio-economic differentials. We focus our attention on the experience of Azerbaijan, India, and South Korea as instances of three distinct SRB trajectories. Finally, we discuss scenarios concerning the future of these sex imbalances and the implications of a consistent number of "missing women" for affected societies.

Trends, Regional Variations, and Socioeconomic Disparities in Cesarean Births in India, 2010-2016.

Importance: The World Health Organization recommends that rates of cesarean delivery range from 10% to 15%. India has the largest annual number of births in the world and needs updates of existing estimates. Objective: To provide a new set of estimates of the rates of cesarean delivery and to map regional and socioeconomic disparities within these rates in India. Design, Setting, and Participants: Cross-sectional study primarily based on cross-sectional figures drawn from the fourth round of the National Family and Health Survey conducted from January 20, 2015, through December 4, 2016, by the Indian Institute for Population Sciences in Mumbai. The survey interviewed 699 686 girls and women aged 15 to 49 years and collected information on their last 3 pregnancies since January 2010 (259 627 births). The study population was statistically representative of India's 36 states and Union territories and its 640 districts. The survey also included information on the socioeconomic status of households. The research is based on data tabulations and mapping and on spatial and regression analyses of microdata. Socioeconomic inequalities in access to cesarean deliveries were assessed using the Gini coefficient. Data were analyzed from August to October 2018. Main Outcomes and Measures: Rate of cesarean deliveries by regional and socioeconomic characteristics. Results: The cesarean birth rate computed for 699 686 Indian girls and women aged 15 to 49 years (mean [SD] age, 26.8 [5.0] years) was 17.2% (95% CI, 17.1%-17.3%) in 2010 to 2016, which corresponds to an estimated 4.38 million cesarean deliveries per year during the period (95% CI, 4.34-4.41 million) in India. Cesarean birth rates vary widely within the country, with a range of 5.8% (95% CI, 5.1%-6.5%) to 40.1% (95% CI, 38.4%-41.8%) across states and 4.4% (95% CI, 4.3%-4.6%) to 35.9% (35.4%-36.4%) across socioeconomic quintiles. The rate significantly increased from 9.2% (95% CI, 9.1%-9.3%) in 2004 to 2008. According to the recommended 10% to 15% benchmark of cesarean birth rates by the WHO, the estimated deficit of cesarean births in India is 0.5 million per year, whereas the estimated excess of cesarean births is 1.8 million. The overall Gini coefficient of inequality in access to cesarean deliveries is 46.4. Conclusions and Relevance: The rate of cesarean births is increasing in India and has already crossed the World Health Organization threshold of 15%. More research is needed to understand the factors behind the rapid rise of cesarean deliveries among affluent groups and in more developed regions.

Excess under-5 female mortality across India: a spatial analysis using 2011 census data.

BACKGROUND: Excess female mortality causes half of the missing women (estimated deficit of women in countries with suspiciously low proportion of females in their population) today. Globally, most of these avoidable deaths of women occur during childhood in China and India. We aimed to estimate excess female under-5 mortality rate (U5MR) for India's 35 states and union territories and 640 districts. METHODS: Using the summary birth history method (or Brass method), we derived district-level estimates of U5MR by sex from 2011 census data. We used data from 46 countries with no evidence of gender bias for mortality to estimate the effects and intensity of excess female mortality at district level. We used a detailed spatial and statistical analysis to highlight the correlates of excess mortality at district level. FINDINGS: Excess female U5MR was 18·5 per 1000 livebirths (95% CI 13·1-22·6) in India 2000-2005, which corresponds to an estimated 239 000 excess deaths (169 000-293 000) per year. More than 90% of districts had excess female mortality, but the four largest states in northern India (Uttar Pradesh, Bihar, Rajasthan, and Madhya Pradesh) accounted for two-thirds of India's total number. Low economic development, gender inequity, and high fertility were the main predictors of excess female mortality. Spatial analysis confirmed the strong spatial clustering of postnatal discrimination against girls in India. INTERPRETATION: The considerable effect of gender bias on mortality in India highlights the need for more proactive engagement with the issue of postnatal sex discrimination and a focus on the northern districts. Notably, these regions are not the same as those most affected by skewed sex ratio at birth. FUNDING: None.

Gender bias in reproductive behaviour in Georgia, Indonesia, and Vietnam: An application of the own-children method.

I present a method for estimating indicators of gender bias in reproductive behaviour, using microdata based on the own-children method. The method is first tested on a large sample from India with both birth history and household records. I then apply the method to Georgia, Indonesia, and Vietnam. My estimates demonstrate that the proportion of Georgian couples expressing a preference for sons in their fertility behaviour closely corresponds to the proportion resorting to sex selection at high parities. I show how individual Indonesian provinces provide examples of both son and daughter preference. The method also allows me to date the onset of sex imbalances at birth in Vietnam. The approach based on the own-children method therefore provides a unique tool for estimating the diversity and intensity of gender bias in reproductive behaviour.

Mapping the diversity of gender preferences and sex imbalances in Indonesia in 2010.

Indonesia is usually viewed as a country free of the acute forms of gender discrimination observed elsewhere in East or South Asia, a situation often ascribed to Indonesia's bilateral kinship system. I re-examine this hypothesis by focusing on ethnic and regional variations in sex differentials. New indicators of marriage practices and gender bias derived from 2010 census microdata highlight the presence of patrilocal patterns as well as a distinct presence of son preference in fertility behaviour in many parts of the archipelago. I also present evidence for excessive child sex ratios and excess mortality of females in some areas that appear to be related to son preference and patrilocal residence systems. The findings confirm the association between son preference, sex differentials in mortality, prenatal sex selection, and kinship systems. I conclude with a more regional perspective on demographic vulnerability of females, distinguishing bilateral South East Asia from more patrilineal Melanesia.

Son preference, sex selection, and kinship in Vietnam.

This article examines the recent rise in the sex ratio at birth in Vietnam and relates its emergence to kinship systems and ethnic composition using 2009 census micro-data. Presentation of the main socioeconomic and ethnic differentials in birth masculinity is followed by a review of the three intermediate factors leading to increases in the sex ratio at birth: prenatal technology, declining fertility, and gender bias. An indirect measurement of fertility behavior is used to demonstrate the close association between levels of the sex ratio at birth and the intensity of son preference. Data on household composition indicate that Vietnam is characterized by the co-existence of kinship patterns typical of East and Southeast Asia. Son preference in Vietnam is found to be related to the prevalence of more traditional patrilineal systems. The article concludes by considering the implications of the cultural dimensions of prenatal sex selection for policy responses and for the likely future change in the sex ratio at birth.

Skewed sex ratios at birth and future marriage squeeze in China and India, 2005-2100.

I examine the potential impact of the anticipated future marriage squeeze on nuptiality patterns in China and India during the twenty-first century. I use population projections from 2005 to 2100 based on three different scenarios for the sex ratio at birth (SRB). To counteract the limitations of cross-sectional methods commonly used to assess the severity of marriage squeezes, I use a two-sex cohort-based procedure to simulate marriage patterns over the twenty-first century based on the female dominance model. I also examine two more-flexible marriage functions to illustrate the potential impact of changes in marriage schedules as a response to the marriage squeeze. Longitudinal indicators of marriage squeeze indicate that the number of prospective grooms in both countries will exceed that of prospective brides by more 50% for three decades in the most favorable scenario. Rates of male bachelorhood will not peak before 2050, and the squeeze conditions will be felt several decades thereafter, even among cohorts unaffected by adverse SRB. If the SRB is allowed to return to normalcy by 2020, the proportion of men unmarried at age 50 is expected to rise to 15% in China by 2055 and to 10% in India by 2065. India suffers from the additional impact of a delayed fertility transition on its age structures.

Socio-economic differentials in birth masculinity in China.

This article examines the relationship between birth masculinity and socio-economic levels in China. Both 2000 and 2005 data suggest the presence of a non-linear relationship between the sex ratio at birth and socio-economic status, with a lower sex ratio at birth observed among both the poorest and the richest households. This inverted-U pattern is significantly different from what is observed in India and what has been assumed previously for China. Multivariate analyses indicate that this pattern persists after the introduction of several other covariates of birth masculinity such as ethnicity, fertility, migration status, age or parity. These results suggest that further economic advances and socio-economic mobility could contribute to the return to normalcy of the sex ratio at birth.

Recent increase in sex ratio at birth in Viet Nam.

INTRODUCTION: Since the 1980s, sex ratio at birth (male births per 100 female births) has increased in many Asian countries as a result of selective abortions, but to date there has been no such evidence for Viet Nam. Our aim in this paper is to ascertain the situation with respect to sex ratio at birth in Viet Nam over the past five years. MATERIALS AND METHODS: Original data were obtained from sample population surveys in Viet Nam recording annual birth rates since 2000 of about 450,000 women, as well as from two successive birth surveys conducted for the first time in 2007 (1.1 million births). The annual population surveys include specific information on birth history and mothers' characteristics to be used for the analysis of trends and differentials in sex ratio at birth. RESULTS AND DISCUSSION: Birth history statistics indicate that the SRB in Viet Nam has recorded a steady growth since 2001. Starting from a level probably close to the biological standard of 105, the SRB reached 108 in 2005 and 112 in 2006, a value significantly above the normal level. An independent confirmation of these results comes from the surveys of births in health facilities which yielded a SRB of 110 in 2006-07. High SRB is linked to various factors such as access to modern health care, number of prenatal visits, level of higher education and employment status, young age, province of residence and prenatal sex determination. These results suggest that prenatal sex determination followed by selective abortion has recently become more common in Viet Nam. This recent trend is a consequence of various factors such as preference for sons, declining fertility, easy access to abortion, economic development as well as the increased availability of ultrasonography facilities.