# **1 Introduction**

Research on missing women has documented severe gender bias at birth and at young ages due to pervasive son preference in India and other Asian countries (Das, 1987; Das Gupta, 1987; Sen, 1990; Arnold, Kishor and Roy, 2002; Jha et al., 2006, 2011). Recent studies confirm these previous findings but also demonstrate that most women are instead missing at adult ages (Anderson and Ray, 2010, 2012; World Bank, 2011).<sup>1</sup><sup>_,_2</sup> Anderson and Ray (2012) find a large state-wise variation in the distribution of excess mortality across age groups in India and argue that the traditional explanation of strong preference for male children can only explain the phenomenon of missing women in states with abnormally male-biased sex ratios _at birth_ . They contend that the explanation for excess mortality in adulthood must reside in other, unspecified, factors.<sup>3</sup> This paper provides evidence that, on the contrary, strong son preference is also partly responsible for high mortality rates among adult women.

India has the world’s largest number of maternal deaths. The ‘female disadvantage in mortality during the reproductive ages is in part driven by the risk of death in pregnancy and childbirth and associated long-term disabilities’ (World Bank, 2011, p. 78). It is estimated that for every maternal death there are twenty other women who suffer pregnancy-related illness, infection, injury, and other physical and psychological long-term consequences (Nanda, Switlick, and Lule, 2005; Filippi et al., 2006; UNICEF, 2008). Anemia, one of the most common indirect causes of maternal mortality in Asia, is pervasive among Indian women. Medical research has shown that repeated and closely spaced pregnancies are associated with increased risk of maternal mortality and morbidity. This behavior is common among women who have only daughters and want to conceive again for a son. The diffusion of prenatal sex diagnostic technologies in the late 1980s has been found to be associated with increasing sex ratios at birth (the fraction of male births) in India which is strongly suggestive of sex selection (Arnold, Kishor, and Roy, 2002; Bhalotra and Cochrane, 2010). Research

> 1Missing women, or excess female mortality, is based on a counterfactual in which there is no discrimination based on gender (Sen, 1990). As a counterfactual, Anderson and Ray (2010) use developed countries, while in their study on India, Anderson and Ray (2012) also use Kerala as an alternative benchmark.

2Klasen and Vollmer (2013) challenge the methodology developed in Anderson and Ray (2010) and argue that the data used in their computations are largely unreliable (especially those on adult mortality for sub-Saharan Africa) and use a reference benchmark that does not account for differences in the disease and mortality environment. Anderson and Ray (2012) replicate their decomposition exercise for India and find that their results are robust to using Kerala as a benchmark (rather than developed countries), though of smaller magnitude. It is important to note that the issues at stake in this debate do not alter the motivation for this paper, which is to analyze the factors contributing to the high number of maternal deaths in India. High maternal mortality is certainly partly due to generally poor health conditions and services and, as argued in this paper, it is _aggravated_ by strong son preference.

> 3Jayaraman, Ray, and Wang (2013) find evidence that women seek treatment for eye care later than men, while they do not seem to receive less surgical care in India.

2