Other economists, notably Emily Oster , have questioned Sen's explanation, and argued that the shortfall was due to a higher prevalence of the hepatitis B virus in Asia compared to Europe; however, her later research established that Hepatitis B cannot account for more than an insignificant fraction of the missing women.
In addition to the health and wellbeing of women, the missing women phenomenon has led to an excess of males in society and an imperfectly balanced marriage market. Because of the association of missing women with female neglect, countries with higher rates of missing women also tend to have higher rates of women in poor health, leading to higher rates of infants in poor health.
Researchers argue that increasing women's education and women's employment opportunities can help decrease the number of missing women, but the effects of these policy solutions differ greatly between countries due to differing levels of ingrained sexism between cultures. According to Sen, even though women make up the majority of the world's population, the proportion of women in each country's population varies drastically from country to country, with various countries having fewer women than men. Unlike female mortality rates, estimates of "missing women" include counts of sex-specific abortions, which Sen cites as a large factor contributing to the disparity of sex ratios from country to country.
Sen's original research found that while there are typically more women than men in European and North American countries at around 0. For example, in China, the ratio of men to women is 1. The ratio is much higher than that for those born after , when ultrasound technology became widely available. Using actual numbers, this means that in China alone, there are 50 million women "missing" — that should be there but are not. Adding up similar numbers from South and West Asia results in a number of "missing" women higher than million. According to Sen, "These numbers tell us, quietly, a terrible story of inequality and neglect leading to the excess mortality of women.
Since Sen's original research, continued research in the field has led to varying estimates on the total numbers of missing women. Much of this variation is because of underlying assumptions for "normal" birth sex ratios and expected post-birth mortality rates for men and women.
Sen's original calculations using s and s data for missing women were indexed using the average sex ratio in Western Europe and North America as the natural sex ratio, through assuming that in these countries men and women received equal care.
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After further research, he updated these numbers with Sub-Saharan African sex ratios. Using these countries' sex ratios as the baseline and male-female populations from other countries as the data, he concluded that over million women were missing, primarily in Asia. As a result of this disparity between countries, American demographer Coale re-estimated the Sen's original numbers of missing women using a different methodology.
Using data from his Regional Model Life Tables , Coale found that the natural male-to-female sex ratio, accounting for different country fertility rates and circumstances, had an expected value of 1. Using the number, he then arrived at an estimate of 60 million missing women, much lower than Sen's original estimate. Furthermore, Klasen and Wink noted that both Sen's and Coale's methodologies were flawed because Sen and Coale assume that optimal sex ratios are constant across time and space, which they are often not.
Klasen and Wink conducted a study in with updated census data. Using life expectancy to instrument for sex ratio at birth which would account for non-constant sex ratios as well as biases from the Regional Model Life Tables , they estimated million missing women across the world. Later estimates have tended to have higher numbers of missing women.
For example, a study estimated that over 90 million females were "missing" from the expected population in Afghanistan , Bangladesh , China , India , Pakistan , South Korea and Taiwan alone. Even within countries, the prevalence of missing women can vary drastically. Das Gupta observed that the preference for boys and the resulting shortage of girls was more pronounced in the more highly developed Haryana and Punjab regions of India than in poorer areas. This prejudice was most prevalent among the more educated and affluent women and mothers in those two regions.
In the Punjab region, girls did not receive inferior treatment if a girl was born as a first child in a given family, when the parents still had high hopes for obtaining a son later. However, subsequent births of girls were unwelcome, because each such birth diminished a chance of the family having a son. Because more affluent and educated women would have fewer offspring, they were therefore under more acute pressure to produce a son as early as possible. As ultrasound imaging and other techniques increasingly allowed early prediction of the child's sex, more affluent families opted for an abortion.
Alternatively, if the girl was born, the family would decrease her chance of survival by not providing sufficient medical or nutritional care. As a result, in India there are more missing women in developed urban areas, than in rural regions. On the other hand, in China, rural areas have a larger missing women problem than urban areas. China's regional differences lead to different attitudes towards the one-child policy.
Urban areas have been found to be easier to enforce the policy, due to the danwei system, a generally more educated urban population — understanding that one child is easier to care for and keep healthy than two. In more rural areas where farming is labor-intensive and couples depend on male offspring to take care of them in old age, males children are preferred to females. Even developed countries face problems with missing women.
The bias against girls is very evident among the relatively highly developed, middle-class dominated nations Taiwan , South Korea , Singapore , Armenia , Azerbaijan , Georgia and the immigrant Asian communities in the United States and Britain. Only recently and in some countries particularly South Korea have the development and educational campaigns begun to turn the tide, resulting in more normal gender ratios.
Some evidence suggests that in Asia, especially in China with its one-child policy , additional fertility behavior, infant deaths, and female birth information may be hidden or not reported. Instead of policy expanding women's opportunities for gainful employment policy, from onward the one-child policy has added upon the son preference causing the largest number of missing women in any country.
In the other direction, migration, especially to GCC countries, has become a larger issue for sex ratio estimates. Because many male migrants move across borders without their families, there is a large influx in the number of males, which would bias the sex ratios towards more missing women, even when there are not. Sen argued that the disparity in sex ratio across eastern Asian countries like India, China, and Korea when compared to North America and Europe, as seen in , could only be explained by deliberate nutritional and health deprivations against women and female children.
These deprivations are caused by cultural mechanisms, such as traditions and values, that vary across countries and even regionally within countries. This is especially true in the medical care given to men and women, as well as prioritizing who gets food in less privileged families, leading to lower survival rates than if both genders were treated equally. According to Sen's cooperative conflict model,  the relations within the household are characterized by both cooperation and conflict: These intra-household processes are influenced by perceptions of one's self-interest , contribution and welfare.
One's fall back position is the situation for each party once the bargaining process has failed and also determines the ability of each party to survive outside of the relationship. Typically, the fall-back position for men who have land ownership rights, more economic opportunities and less care work related to children is better than a woman's fall-back position, who is dependent on her husband for land and income.
According to this framework, when women lack a perception of personal interest and have greater concern for their family welfare gender inequalities are sustained. Sen argues that women's lower bargaining power in household decision contributes to the shortfall in female populations across eastern Asia. Sen argues that the trend of lower female bargaining power may be positively correlated to the outside earning power and sense of contribution of women when compared to men.
However, not all forms of outside work contribute equally to increasing women's bargaining power in the household; the type of outside work women do has bearing on their entitlements and fall-back position. Women can be doubly exploited in some cases: Since lace-making is done in the home, it is perceived as only supplementary to male work rather than a gainful outside contribution.
On the other hand, in Allahabad, India, women making cigarettes both gained an independent source of income and an increase in the community's view of their perceived contribution to the household. Sen suggests that in areas with high proportions of missing women, the care and nutrition female children receive are tied to the community's view of their importance. Parents, even mothers, often avoid daughters because of the traditional patriarchal culture in the countries where the elimination of females takes place.
Boys are more prized in these regions because they are looked upon as having an economically productive future, while women are not. As parents grow older they can expect much more help and support from their independent sons, than from daughters, who post-marriage functionally become the property of their husbands' families.
Even if these daughters are educated and generate significant income, they have limited ability to interact with their natal families. Women are also often practically unable to inherit real estate, so a mother-widow will lose her family's in reality her late husband's plot of land and become indigent if she had had only daughters. Poor rural families have meager resources to distribute among their children, which reduces the opportunity to discriminate against girls. Because of selective parental valuation of daughters, even as women are able to afford better healthcare and economic opportunities outside the home, the missing women problem still persists.
Notably, ultrasound technology has exacerbated the problem of missing female children. Ultrasound treatment allows parents to screen out unwanted female fetuses before they are even born. Sen refers to this inequality as "high tech sexism. Sen then argued that instead of just increasing women's economic rights and opportunities outside the home a greater emphasis needed to be placed on raising consciousness to eradicate the strong biases against female children.
The natural sex ratio at birth is approximately males for females. Various researchers argue that declining fertility contributes to an intensified problem of missing women. China due to the One Child Policy , fertility is not often associated with higher prevalence of missing women. In fact, as Klasen notes, "In countries where fertility decline has been the largest, the share of missing women has fallen the most.
However, this varies between countries. Das Gupta finds that in South Korea, the male-to-female sex ratio spiked from 1. In her PhD dissertation at Harvard , Emily Oster argued that Sen's hypothesis did not take account of the different rates of prevalence of the Hepatitis B virus between Asia and other parts of the world. While the disease is fairly uncommon in US and Europe, it is endemic in China and very common in other parts of Asia. Furthermore, Oster showed that the introduction of a Hepatitis B vaccine had a lagged effect of equalizing the gender ratio towards what one would expect if other factors did not play a role.
Oster's challenge was met with counter arguments of its own as researchers tried to sort out the available data and control for other possible confounding factors.
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Avraham Ebenstein questioned Oster's conclusion based on the fact that among first born children the sex ratio is close to the natural one. It is the skewed female-male ratios among second and third born children that account for the bulk of the disparity. In other words, if Hepatitis B was responsible for the skewed ratio then one would expect it to be true among all children, regardless of birth order. However, the fact that the skewness arose less among the later born than among the first born children, suggested that factors other than the disease were involved.
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Das Gupta pointed out that the female-male ratio changed in relation to average household income in a way that was consistent with Sen's hypothesis but not Oster's. Furthermore, Das Gupta documented that the gender birth order was significantly different conditional on the sex of the first child. If the first child was male, then the sex of the subsequent children tended to follow the regular, biologically determined sex pattern boys born with probability 0.
However, if the first child was female, the subsequent children had a much higher probability of being male, indicating that conscious parental choice was involved in determining the sex of the child. Neither of these phenomena can be explained by the prevalence of hepatitis B. They are, however, consistent with Sen's contention that it is purposeful human action — in the form of selective abortion and perhaps even infanticide and female infant neglect — that is the cause of the skewed gender ratio. Part of the difficulty in discerning between the two competing hypotheses was the fact that while the link between Hepatitis B and a higher likelihood of male birth had been documented, there was little information available on the strength of this link and how it varied by which of the parents were the carriers.
Furthermore, most prior medical studies did not use a sufficiently high number of observations to convincingly estimate the magnitude of the relationship. However, in a study published in the American Economic Review , Lin and Luoh utilized data on almost 3 million births in Taiwan over a long period of time and found that the effect of maternal Hepatitis B infection on the probability of male birth was very small, about one quarter of one percent.
The remaining possibility was that it was the infection among fathers that could lead to a skewed birth ratio. As a result, Oster retracted her earlier hypothesis. In a study, Anderson and Ray claim that other diseases may explain the "excess female mortality" across Asia and sub-Saharan Africa.
They find that by and large, the main cause for female deaths in India is cardiovascular disease. Both of these causes are far greater than maternal mortality and abortion of fetuses, though "Injuries" may be directly related to gender discrimination. Their findings for China also attribute missing women of older ages to cardiovascular and other non-communicable diseases, accounting for a large portion of excess female deaths. However, the largest bracket of missing women is in the age group, suggesting discrimination factors at work in accordance to Sen's original theories.
In sub-Saharan Africa, in contrast to Sen's contention and average statistics, Anderson and Ray find a large number of women are missing.
The Crisis and Miss Emily's Perceptions
Just as Sen believed, in their study they find no evidence to impute the missing women to birth discrimination such as sex-selective abortions or neglect. The age groups with the highest numbers of missing women were the to and to year-old ranges. In countries where women cannot own property they are in a more precarious fall-back position, having less bargaining power to "insist on safe sex without risking abandonment" by their husbands.
Stillwaggon argues for increased focus on sanitation and nutrition rather than just abstinence or safe sex. As women become healthier the chances of an infected female transmitting HIV to a male partner decline significantly. Other scholars question the assumed normal sex ratio, and point to a wealth of historical and geographical data that suggest sex ratios vary naturally over time and place, for reasons not properly understood.
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