serious public health issue in India (Gragnolati et al., 2005).

# **2.2 Fertility behavior and maternal health outcomes**

It has been argued that in contexts where the preference for male children is pervasive, parents alter their fertility choices and can exhibit overt discrimination against their unborn and living female children (Das Gupta, 1987; Das, 1987; Clark, 2000; Arnold, Kishor, and Roy, 2002; Jha et al., 2006). Parents can ensure the desired number of sons in two main ways. First, they can avoid the birth of unwanted daughters by eliminating female fetuses through sex-selective abortion. Several studies have noted that increasing sex ratios at birth in India match the timing of the diffusion of prenatal sex determination technologies in the late 1980s (Arnold, Kishor, and Roy, 2002; Bhalotra and Cochrane, 2010). These and other studies (Das Gupta, 1987, and Jha et al., 2011) have also documented that sex selection is more common among educated women and richer families. Another key finding of this literature is that there is no evidence of sex selection at first birth (Das Gupta, 1987; Bhat and Zavier, 2007; Jha et al., 2011). Second, women can continue childbearing until the desired sex composition of children is reached, commonly known as son-preferring stopping behavior (as women with daughters only are more likely to keep having children) (Chowdhury and Bairagi, 1990; Clark, 2000; Dreze and Murthi, 2001; Arnold, Kishor, and Roy, 2002; Filmer, Friedman and Schady, 2009). Other authors have also shown that a female birth is associated with shorter birth intervals (Trussel et al., 1995; Arnold, Choe, and Roy, 1998), and shorter breastfeeding (Jayachandran and Kuziemko, 2011). In this paper, I use ‘son-preferring fertility behavior’ to refer to both stopping as well as reduced birth interval.

The adverse health consequences of a high number of births and short spacing between births are well documented in the medical literature. A high number of pregnancies is associated with higher lifetime risk of death due to pregnancy.<sup>14</sup> Medical research has shown that birth intervals shorter than 24 months are associated with poor child and maternal health outcomes (Setty-Venugopal and Upadhyay, 2002; King, 2003).<sup>15</sup> Closely spaced pregnancies increase the risk of maternal nutrient depletion as the mother is not allowed sufficient time to restore the adequate supply of nutrients needed to have a successive successful pregnancy (Sharman, 2000; King, 2003). Conde-Agudelo, and Belizan (2000) use a large cross-sectional dataset covering 456,889 women from 18 Latin American countries and find that, compared to women giving birth at 27 to 32-month intervals, women

> 14The adult lifetime risk of maternal mortality is defined as “the probability that a 15-year-old female will die eventually from a maternal cause if she experiences throughout her lifetime the risks of maternal death and the overall levels of fertility and mortality that are observed for a given population” (WHO, 2010, pp. 14). It is related to both the mortality associated with a single pregnancy and the number of pregnancies a woman has in her reproductive years (UNICEF, 2008).

> 15Birth interval (or birth spacing) refers to the time interval (number of months) between births (i.e., the length of time from birth to next conception plus nine months).

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