Published Oct 30, 2026 | 6:07 PM ⚊ Updated Oct 30, 2026 | 6:07 PM
Kerala recorded the lowest anaemia prevalence among girls in these households.
Synopsis: A study using NFHS-5 data found higher anaemia prevalence among girls in households reporting son preference. However, the association weakened after socioeconomic factors were considered. Maternal education, household wealth and maternal anaemia emerged as important factors, while the association persisted in eastern India, highlighting the need for region-specific interventions.
A family’s preference for sons may have implications for girls’ health, including their nutrition and access to care. But the relationship between gender bias and anaemia is not straightforward. Poverty, maternal education and other social factors also shape children’s health.
A study published in Global Social Welfare examined this relationship using data from the National Family Health Survey-5 (NFHS-5), conducted in 2019–21. The researchers analysed 88,677 girls aged 6–59 months to assess whether son preference was associated with a higher prevalence of anaemia.
Son preference is the ancient and cross-cultural human preference for male (rather than female) offspring.
“Son preference remains a deeply rooted norm in India, potentially influencing the health and nutritional status of girls,” the authors wrote. They noted that anaemia among young children, particularly girls, remains a significant public health concern.
Girls in households reporting son preference had a higher prevalence of anaemia in the initial analysis. However, the association weakened after the researchers accounted for socioeconomic and demographic factors.
The difference in anaemia prevalence was modest but noticeable. Among girls living in households that preferred sons, 70.81 percent were anaemic. The corresponding figure was 67.48 percent in households that did not report son preference, a gap of 3.33 percentage points.
The researchers then used statistical models to examine whether this difference persisted after accounting for other characteristics.
In the initial model, girls in son-preferring households had 14 percent higher odds of anaemia. The difference narrowed to 6 percent after the researchers adjusted for characteristics at the child level.
Once maternal and household factors were included, the association was no longer statistically significant. This means the analysis did not establish an independent association between son preference and anaemia at the national level after those factors were considered.
The authors said the findings suggested that son preference often exists alongside wider social and economic disadvantages.
“Although unadjusted model indicated a higher anemia burden among girls in households expressing son preference, this association became non-significant after adjusting for socioeconomic and demographic characteristics,” they wrote. “However, regional analyses particularly in Eastern India indicated a persistent association.”
The study discusses possible ways in which gender bias could affect girls. These include differences in food allocation, healthcare use and parental attention. However, the survey did not directly measure whether girls received less food or were denied medical care because their families preferred sons.
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The researchers used a decomposition analysis to examine which characteristics contributed to observed differences in anaemia prevalence. Maternal education accounted for the largest reported share nationally, at 59.33 percent. Household wealth contributed 25.91 percent, maternal anaemia status 14.18 percent and caste 7.54 percent.
The association between maternal education and anaemia was clear. Among girls whose mothers had no formal education, 73.54 percent were anaemic. The prevalence fell to 61.43 percent among girls whose mothers had higher education.
The researchers also found a difference according to mothers’ nutritional status. Anaemia affected 72.97 percent of girls whose mothers were anaemic, compared with lower prevalence among girls whose mothers were not anaemic. Girls whose mothers were underweight also had a higher prevalence, at 72.23 percent.
The authors suggested that education could influence children’s health through several pathways.
“Maternal education may be associated with anemia status through differences in nutritional knowledge, healthcare utilization, and hygiene practices,” they wrote. They also cited previous research linking a lack of formal education among mothers with a greater likelihood of severe anaemia in children.
Household income showed a similar pattern. Nearly three in four girls in the poorest households were anaemic, at 72.95 percent. Among girls in the richest households, the figure was 62.73 percent.
Place of residence also mattered. Anaemia prevalence stood at 69.19 percent among girls in rural areas, compared with 64.8 percent among those in urban areas. The study also reported higher prevalence among girls from Scheduled Caste and Scheduled Tribe communities, at 71.54 percent.
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In eastern India, son preference remained significantly associated with anaemia even after the researchers adjusted for child, maternal and household characteristics.
Girls in households reporting son preference had 10 percent higher odds of anaemia in the fully adjusted model.
The authors suggested that entrenched gender norms and discriminatory caregiving practices could help explain the regional difference. They discussed possible disparities in food allocation, healthcare use, breastfeeding duration and birth intervals.
However, these pathways were not directly measured in the survey. The findings establish a persistent statistical association in eastern India, not proof of the specific practices responsible for it.
The pattern differed elsewhere. In western, northern and southern India, associations seen in the initial models were no longer statistically significant after adjustment. In the Northeast, the researchers found no statistically significant association across the models.
Regional differences were also evident in overall anaemia prevalence among girls. Southern India recorded the lowest prevalence, at 59.62 percent. The western region had the highest, at 72.88 percent. Prevalence stood at 70.07 percent in the North, 70.04 percent in the East, 68.44 percent in Central India and 64.38 percent in the Northeast.
State-level comparisons showed considerable variation across all five southern states, even among households reporting son preference. Kerala recorded the lowest anaemia prevalence among girls in these households, at 35 percent, followed by Andhra Pradesh at 63.4 percent. Tamil Nadu reported 60 percent, while Telangana recorded 71.2 percent and Karnataka 72.6 percent. These figures describe anaemia prevalence within each state’s household category; they do not establish that son preference explains the differences between states.
The study also found that high anaemia burdens persisted in some places where households did not report son preference.
The authors pointed to factors such as poverty, low maternal education, poor dietary diversity, maternal undernutrition and limited access to health services as possible contributors.
The decomposition analysis also showed that the factors associated with disparities varied by region.
Maternal education accounted for 27 percent of the explained disparity in southern India. In the West, household wealth was the largest reported contributor, at 63.47 percent. In the Central region, birth order accounted for 48.01 percent, while maternal education also made a substantial contribution. In the Northeast, religion contributed 57.33 percent and maternal anaemia status 29.82 percent.
These figures are statistical decomposition estimates, not proof that any one characteristic directly causes the observed differences. Individual contributions can exceed 100 percent or be negative in this type of analysis because factors may work in opposing directions.
The researchers acknowledged important limitations. Son preference was measured through mothers’ stated ideal numbers of sons and daughters. A mother was classified as preferring sons if her ideal number of sons exceeded her ideal number of daughters.
This measure offers a way to compare households across a large national survey. But it does not reveal how parents actually treat their children or how they distribute food and healthcare within the household.
The survey also lacked information on some factors directly relevant to anaemia, including dietary diversity, iron supplementation, deworming and the consumption of iron-rich foods. The researchers therefore could not determine how these factors influenced the relationship between son preference and anaemia.
The study’s cross-sectional design presents another limitation. It captures associations in survey data but cannot establish cause and effect.
These gaps mean the findings should not be interpreted as evidence that every household expressing son preference discriminates against girls, or that gender bias alone explains their anaemia risk.
The authors called for a broader approach to reducing anaemia among girls. They argued that nutritional interventions should be accompanied by efforts to improve maternal education, reduce poverty and address maternal health.
“Ultimately, sustainable anemia reduction requires recognizing that while gender bias persists regionally, structural factors are the primary drivers,” they wrote. They recommended combining nutritional supplementation with socioeconomic interventions.
They also called for region-specific approaches. Their analysis points to maternal education as an important contributor to disparities in the South, while the factors associated with differences elsewhere include household wealth, birth order, religion and maternal anaemia.
(Edited by Dese Gowda)
