Abortion clinics have frequently been subject to anti-abortion violence.  The New York Times  cites over 100 clinic bombings and incidents of arson, over 300 invasions, and over 400 incidents of vandalism between 1978 and 1993, [ 30 ]  and the  National Abortion Federation , an organization of abortion providers, cites over 300 attempted or completed instances of bombing or arson, thousands of invasions and vandalism incidents, as well as other attacks, between 1977 and 2009. [ 31 ]  According to the NAF, the first instance of arson at an abortion clinic took place in March 1976 in Oregon, and the first bombing was in Ohio in February 1978. [ 32 ]


In the United States, the  Freedom of Access to Clinic Entrances Act  was passed in 1994 in response to acts of violence at clinics, which prohibits the use of force or obstruction to interfere with a person's attempt to obtain or provide reproductive health services, and the intentional damage of a reproductive health care facility such as an abortion clinic.


Definitions of abortion  vary from one source to another.  Abortion  has many definitions that can differ from each other in significant ways. Given the contentious nature of abortion, lawmakers and other stakeholders often face controversy in defining abortion. [ 1 ] [ 2 ]
Language referring to abortion often reflects societal and political  opinions  (not only scientific knowledge). [ 3 ]
Influential non-state actors like the  United Nations [ 4 ]  and the  Roman Catholic Church  have also engendered controversy over efforts to define abortion. [ 5 ]


Late termination of pregnancy  is the term usually used for later uterine evacuation. [ 6 ]


Ambiguous definitions can create concerns in the medical community. [ 7 ]  Physicians in several countries, including Ireland [ 8 ] [ 9 ]  and Canada, [ 10 ]  have expressed concern over ambiguous definitions of abortion. Even in situations where there is a clear definition of abortion, it does not always match definitions of related terms in effect in the same  jurisdiction . [ 11 ]


The following is a partial list of definitions as stated by  obstetrics and gynecology  (OB/GYN) textbooks, dictionaries, and  encyclopedias :


Major OB/GYN textbooks


Other OB/GYN textbooks


Major  medical dictionaries


Other medical dictionaries


Bibliographies


Major English dictionaries  (general-purpose)


Other dictionaries


Encyclopedias


Philosophical essays


Departurism [ 1 ] [ 2 ] [ 3 ]  is an  anti-abortion   libertarian  approach to the  reproductive rights  controversy developed by American philosopher Sean Parr which argues, contrary to  evictionism , [ 4 ]  that the lethal removal of an unwanted  fetus  ought to be legally impermissible (except in cases where the  pregnancy  jeopardizes the life of the mother). [ 5 ]


Both departurism and evictionism acknowledge that a fetus is a  distinct ,  living   human being  and, further, admit their  personhood . [ 6 ]


There are two aspects of these theories that make them uniquely libertarian:


Moreover, both theories argue that the fetus lacks  mens rea  in his occupation of the mother's womb, so the mother's treatment of the fetus must follow the principle of gentleness. [ 10 ] [ 11 ]


Gentleness is an  ex ante  element of law—similar to the  ex post  element,  proportionality —which states that if the victim of an invasion intends to halt it while it is occurring, they must only use the least severe measures necessary to do so. Failing to use the gentlest means possible to end  non-criminal aggression , places the victim "at risk of falling on the wrong side of the  non-aggression principle ," [ 12 ]  violating it "to a far greater extent than is the trespasser." [ 13 ]  Because all fetuses "are equally innocent," [ 14 ]  this attempt to curtail property owners from dealing with such trespassers "more severely than libertarian  punishment  theory allows" [ 15 ]  is applicable to unwanted fetuses who are the result of  rape  no less than those whom are  consensually  conceived. [ 16 ]


Where departurism and evictionism differ is in their understanding of what gentleness ought to look like when it is properly applied to situations of trespass within the womb.


The evictionist view is that the mother may not directly kill the unwanted child (e.g., initiate a  medical abortion , [ 17 ]  non-lethally evict the child and then kill him, [ 18 ]  etc.), but she may indirectly do so by evicting him from her premises during a time in which he is non- viable  outside the womb. This lethal eviction however, if it's to be in accord with gentleness, must proceed only after the relevant authorities [ 19 ]  have been notified to see if they are able and willing to prevent this removal from becoming fatal. [ 20 ]


Departurism, likewise, holds that the mother may evict [ 21 ]  but not directly kill the trespassing fetus, but, contrary to evictionism, neither may she kill him by eviction. The mother, if her actions are to conform to gentleness, must allow for the continued departure of the trespasser until such time that eviction no longer entails his death. That is, "it is only the lethal (or otherwise debilitating) eviction of a fetus during a normal pregnancy that departurism views as discordant with gentleness and, thus, a violation of the NAP." [ 22 ]


Because the requirements of both views (evictionism's  notification  and departurism's  continued departure ) are said to find their justification in gentleness, it is the view whose requirement best conforms to this principle that should be preferable on libertarian grounds.


The departurist argument is an attempt to


First, the departurist argument compares two situations,  S 1  and  S 2 .


S 1  represents the situation of a trespasser who is (a) unable to engage in  human action  and (b) leaving the premises of the property owner, while (c) not endangering the life of the same, and where (d) the eviction of this trespasser will result in his death.  S 2  represents the situation of an unwanted fetus in the uterus of his mother.


Departurism claims that these situations are relevantly similar to each other and therefore cannot be treated differently. That is, the requirement of practical consistency dictates that the same course of action is appropriate in both situations. [ 24 ]


Second, the departurist argument describes a course of action,  A .


A  represents the course of action in which the property owner allows for the trespasser to continue his departure until such time that eviction will not necessitate his death.


Departurism claims that this course of action stops the trespass in a comparatively less harmful manner than does the course of action advanced by evictionism (e.g., it doesn't entail that the inadvertent aggressor be subjected to unjustifiable life-taking or NAP-violating violence). [ 25 ]  That is, the principle of gentleness dictates that this course of action is the correct, libertarian one in either case.


Departurism illustrates a potential expression of  S 1  which includes all of its relevant conditions (a-d). This illustration posits a property, owned by M and on which F is trespassing, which abuts a cliff on its southern border. F, whose mental state or capacity is such that he is incapable of knowing that he is trespassing, [ 27 ]  is travelling along this cliffside from west to east and off of M's property (that is, unwitting F happens to be vacating the premises). Importantly, there is nothing about F's trespass which is seriously endangering M's life. [ 28 ]  M knows that should F be pushed off the cliff while on the western end of the premises (the black area), F will certainly die due to the severe height of the fall. Further, M is aware that a fall from the eastern end of the premises (the white area) will not prove fatal for F due to the negligible distance from the cliffside to ground below. A fall from in between these ends (the gray area) may or may not be deadly. According to departurism,


whether or not a fall from the gray area is fatal depends on the technology available at the time to prevent it from becoming so. To wit, 1000 years ago the gray area would have been all black; 1000 years from now, with technological advances, the gray area will be all white.
Currently, falls from the gray area are more likely to result in death and serious injury the closer they are to the black area, and less likely to result in the same the closer they are to the white area. [ 29 ]


Departurism makes the case that the evictionist-proposed course of action (that M may legally shove F headlong off the cliff and unto the black or western gray areas) is not transformed into a less harsh means of ending the trespass simply because the evictionist notification requirement has first been satisfied (e.g., someone was told about this fatal cliff-tossing beforehand). The departurist indictment goes on to state that this evictionist position represents "nothing if not a textbook example of the very response on the part of the victim that gentleness was placed into libertarian law so as to preclude." [ 30 ]  Moreover, the supposed gentleness of evictionism falls short when compared to the departurist-proposed course of action (that M be prohibited from evicting F unto the black or western gray areas when so doing constitutes a degree of severity inappropriate for bringing an end to this particular trespass).


Evictionism concedes that the following conditions of  S 1  are present in  S 2 :


(a) The trespasser is incapable of purposeful behavior. [ 31 ]


(b) The trespasser is in the process of departing the property owner's premises. [ 32 ]


Although the evictionist has made no quarrel with either of these points, departurism has elucidated how the latter condition relates to  S 2  in the following way:


It can be assumed that every pregnancy begins at the western end of M's premises. From fertilization to parturition, the process of gestation takes the fetus from the western to the eastern end (and off) of M's premises. The fetus, as a matter of fact, is departing the premises of the property owner and he is so doing from the moment that he first arrives there—regardless of the point at which he is deemed a trespasser. [ 33 ]


Furthermore, evictionism does not dispute the presence in  S 2  of the remaining conditions of  S 1 —as these conditions represent, respectively, the most prevalent and the most relevant instances of uterine trespass:


(c) The trespasser is not jeopardizing the proprietor's life via aggression against property rights in the person.


(d) The trespasser's eviction from said premises would necessitate his death.


Practical consistency prohibits the trespasser in  S 2  from being treated differently from the trespasser in  S 1  because all of the relevant conditions of the latter situation are found also in the former. It is for this reason that departurism holds that


just as it ought to be illicit for M to send F fatally off into the wild blue yonder, it ought also to be illicit for a mother to kill, or otherwise unjustifiably maim, the unwanted fetus in her womb by eviction. [ 34 ]


Departurism charges evictionism with radically conceiving of the gentleness principle not as the least harmful manner possible consistent with stopping the aggression, but as the  most expedient  manner possible consistent with stopping the  aggressor . The departurist claim is that this comprehension destroys the spirit or intended purpose of the gentleness principle by twisting it in order to permit victims of non-criminal aggression to engage in severe reactions and over-responses—the very things which are the principle's purpose to prohibit. [ 35 ]


Both evictionism and departurism contain requirements that the mother withhold the eviction of the unwanted child for some amount of time. For the former, that amount of time is the duration required for the mother's notification of the authorities; for the latter, it is the duration required for the child's continued departure to reach the point at which his eviction no longer necessitates a NAP-violation. The departurist claim is that the evictionist notification requirement constitutes a  positive obligation , and so is anathema to libertarianism. Evictionism's requirement, unlike departurism's, is a positive one because it neither derives from nor constitutes the gentlest manner possible of bringing the fetal trespass to an end. [ 36 ]


It is the departurist view that evictionism transforms libertarianism into an ideology of  squatters  by means of its positive obligation that the mother notify the authorities prior to her lethal eviction of the fetus. The departurist claim is that this permits the fetus to occupy the mother's premises, without her permission, for the duration of that notification.


Departurism further holds that evictionism transforms libertarianism into an ideology of corpses. The evictionist view is that because the trespasser in this case cannot engage in purposeful behavior, the phenomenon of  implicit contracts  is impotent to prevent his lethal eviction from the mother's uterus (even if the duration of his trespass is not onerous). But womb-aged children are not the only category of persons to whom it can be argued that implicit contracts are not applicable. The departurist claim is that, under evictionism,  any guest  who is mentally or developmentally incapable of entering into a contract may have his invitation rescinded by his host at any time, and this newly-designated "trespasser" can then be lethally and lawfully removed from the premises. [ 37 ]  The evictionist has not balked at this characterization of his view, stating that the departurist makes a "not totally unreasonable point." [ 38 ]  The evictionist has even gone on to concede that this "of course sounds horrible," [ 39 ]  before attempting to justify it on  consequentialist  grounds.


Walter Block  has made counter-arguments to departurism. [ 40 ] [ 41 ]


Fundal massage , also called  uterine massage , is a technique used to reduce bleeding and cramping of the  uterus  after  childbirth  or after an  abortion . As the uterus returns to its nonpregnant size, its muscles contract strongly, which can cause pain. Fundal massage can be performed with one hand over the  pubic bone , firmly massaging the uterine  fundus  (the top of the uterus), or with the addition of one hand in the  vagina  compressing the two  uterine arteries . Routine use of fundal massage can prevent  postpartum  or post-abortion hemorrhage and can reduce pain; it may also reduce the need for  uterotonics , medications that cause the uterus to contract. It is used to treat  uterine atony , a condition where the uterus lacks muscle tone and is soft to the touch instead of firm. [ 1 ]


A  mooncalf  (or  moon-calf ) is a  monstrous birth , the  abortive   fetus  of a  cow  or other  farm animal . The term was occasionally applied to an abortive  human  fetus.


The term derives from the once widespread  superstition , present in many  European   folk  traditions, that such malformed creatures were the product of the sinister influence of the  Moon  on fetal development. The earliest recorded use of the term was in 1565, referring to a human  false pregnancy . [ 1 ]


The term came to also refer to any monstrous or grotesque thing.  Shakespeare , for instance, used the term to describe  Caliban , the deformed servant of  Prospero , in  The Tempest .


In  H. G. Wells 's 1901 novel  The first Men in the Moon , large creatures domesticated by the Selenites are referred to as "mooncalves". [ 2 ]


Mooncalf is used as a derogatory term indicating someone is a dullard, fool, or otherwise not particularly bright or sharp. For example,  W. C. Fields  in  The Bank Dick  (1940) advises his prospective son-in-law to avoid being a "mooncalf" by buying shares he has been conned into believing are worth much more than the proffered price.


A mooncalf is also a magical creature in the world of the  Harry Potter  series. It is described in  Fantastic Beasts and where to find them  as a shy, nocturnal creature with a smooth, pale-gray body, bulging eyes, and four spindly legs with large flat feet. Mooncalves perform dances in the moonlight and are apparently responsible for  crop circles . [ 3 ]  In the  film of the same name  and its  sequel , Newt Scamander's collection of creatures in his suitcase includes a herd of mooncalves.


In the fourth episode of the seventh season of  The Big Bang Theory , Sheldon calls Amy a "dewy-eyed mooncalf".


Wilfred Maxwell, narrator and protagonist of  occultist   Dion Fortune 's 1938 novel  The Sea Priestess , refers several times to a mentally disabled character who falls into the sea and disappears as a "mooncalf". [ 4 ]


This concept is also used by  Christian Morgenstern  in his  Galgenlieder .


In  Embassytown  by China Miéville, the protagonist refers to two characters as "mooncalf and quite impossible".


Arnold Bennett used the term in his novel  These Twain .


Paper abortion , also known as a  financial abortion ,  male abortion  or a  statutory abortion , [ 1 ]  is the proposed ability of the  biological father , before the birth of the child, to opt out of any rights, privileges, and responsibilities toward the child, including  financial support . [ 2 ] [ 3 ] [ 4 ]   By this means, before a child is born, a man would be able to absolve himself of both the privileges and demands of fatherhood. [ 1 ] [ 5 ] [ 6 ] [ 7 ]


The concept begins with the premise that when a woman becomes pregnant, she has the option of  abortion ,  adoption , or  parenthood . It argues, in the context of  gender equality , that in the earliest stages of pregnancy the putative (alleged) father should have the same right to relinquish all future parental rights and financial responsibility -- leaving the informed mother with the same three options. At present, the putative father is held financially responsible for a child no matter what the circumstances of conception, including  statutory rape  of the father by the mother (see  Hermesmann v. Seyer ), [ 8 ]  and fraud (the mother used the father's sperm to become pregnant without his knowledge or consent). [ 9 ]


The term "male abortion" was coined by Melanie McCulley, a South Carolina attorney, in a 1998 article, "The Male Abortion: The Putative Father's Right to Terminate His Interests in and Obligations to the Unborn Child". McCulley argued that men should be able to terminate their legal obligations to unwanted children. [ 10 ]  According to McCulley: [ 11 ]


When a female determines she is pregnant, she has the freedom to decide if she has the maturity level to undertake the responsibilities of motherhood, if she is financially able to support a child, if she is at a place in her career to take the time to have a child, or if she has other concerns precluding her from carrying the child to term. After weighing her options, the female may choose abortion. Once she aborts the fetus, the female's interests in and obligations to the child are terminated. In stark contrast, the unwed father has no options. His responsibilities to the child begin at conception and can only be terminated with the female's decision to abort the fetus or with the mother's decision to give the child up for adoption. Thus, he must rely on the decisions of the female to determine his future. The putative father does not have the luxury, after the fact of conception, to decide that he is not ready for fatherhood. Unlike the female, he has no escape route (4).


In a 1996 article "Abortion and Fathers' Rights," [ 12 ]  philosopher Steven Hales made an argument that presupposes the following assertions:


Hales contends that the conjunction of these three principles is prima facie inconsistent and that this inconsistency should be eradicated by firstly acknowledging that men have no absolute duty to provide material support for their children, and secondly by admitting that fathers have the right of refusal.


Laurie Shrage , professor of philosophy and women's and gender studies, questions whether men should be 'penalized for being sexually active', and she puts the subject in the perspective of feminists who had to fight the same idea with different gender portent, namely that consenting to sexual intercourse is not the same as consenting to parenthood. Furthermore, both men and children are punished, according to professor Shrage; children have to live with an absent father who never 'voluntarily' became a parent. [ 13 ] [ 14 ]


[If] women’s partial responsibility for pregnancy does not obligate them to support a fetus, then men’s partial responsibility for pregnancy does not obligate them to support a resulting child.


At most, according to Brake, men should be responsible for helping with the medical expenses and other costs of a pregnancy for which they are partly responsible.


Interestingly, there is overlap between  masculists  and  feminists  on this point. For example, Australian writer and comedian  Catherine Deveny  makes the point that requiring the male to be automatically resigned to forced parenthood is a violation of a man's right to choose when women have various options to absolve the man of parental responsibility; namely, she says, "the options are abortion, adoption, parenting together or sole parenting." Deveny also condemns the antiquated notion of "men [being] obligated to provide for women", which she considers to be reminiscent of "oppressive heteronormative values [that] belong in the 1950s". [ 15 ]  As a solution, Deveney suggests a "no kids yet" register that would give men an opt-out solution that would prevent fathers from being forced to father a child against their will—or at least prevent them from being forced to pay child support.


Paper abortion has met opposition by those who see it as an excuse for men to shirk their responsibilities as a father. [ 16 ] [ 17 ]  Critics say that men should use birth control (either contraception or sterilization) or practice abstinence if they want to avoid the financial and personal responsibilities of fatherhood. [ 18 ] [ 19 ]  This stance does not account for those men who conceive a child even after taking reasonable precautions, or involuntary conception as a result of  birth control sabotage ,  sexual assault ,  statutory rape  of underage boys by adult women, or  sperm theft . [ 20 ]   [ 17 ]


Lilia Lemoine , elected deputy from Argentina and ally of president-elect  Javier Milei , announced that her first bill will be to offer parents the possibility of renouncing paternity. The project determines that the pregnant woman must notify the father of this pregnancy within 15 days and the father will be able to decide whether he wants to recognize the child or not. Lemoine states that if the man does not want to, he will not have the obligation to pay child support. [ 21 ]  According to the deputy, it is unfair for a woman to be able to renounce motherhood by killing her child, referring to the  2020 approval of abortion in Argentina . [ 22 ]


The concept of a paper abortion was first introduced in Denmark in 2000 by the  socioeconomicist  Henrik Platz. He says that it is necessary from an  egalitarian  perspective, to ensure that women and men have equal rights under the law. According to a  Gallup poll  from 2014 and earlier polls, between 40% and 70% of Danes agree with legalizing paper abortion. [ 1 ]


Sociologist Karen Sjørup, who conducted research on the topic [ 23 ]  argues that it would give women more freedom by allowing those who want to become mothers without having to share the rights and duties of parenthood with men an additional way to do so. She also suggests that it could decrease the abortion rate because it would prevent men who wished to avoid fatherhood from pressuring women to abort. [ 24 ]


Advocates argue that just as women are able to choose whether to have a child or not, men should also be able to choose whether to assume paternity or not. Allowing men to have the opportunity to renounce the economic, social and legal responsibility for an unborn child during the first three months of pregnancy would give men and women as close to equal opportunities as possible. [ 13 ]


In 2016, a regional branch of the Swedish  Liberal Youth Party  decided to support paper abortion for men until the 18th week of pregnancy, the time limit on abortions for women. The proposition was supported by some commentators, but not by the LYP's parent party. [ 3 ]


Post-abortion care  ( PAC ) is treatment and counseling for post-abortion women. It includes  curative care , such as treating abortion complications, as well as  preventative care , such as providing  birth control  to prevent future unwanted pregnancies. [ 1 ]  Post-abortion care reduces morbidity and mortality associated with abortion. [ 2 ]


Approximately 75 million women require post-abortion care annually following induced and  spontaneous abortion  (miscarriage). [ 3 ]
All countries have committed to reducing pregnancy-related mortality by providing treatment for abortion complications, regardless if the abortion was illegally obtained. [ 1 ]  However, an analysis of ten countries (Bangladesh, Haiti, Kenya, Malawi, Namibia, Nepal, Rwanda, Senegal, Tanzania, and Uganda) found that in seven of ten, less than 10% of primary facilities could provide basic post-abortion care. No primary healthcare facilities in Namibia provided post-abortion care; Malawi, with greatest prevalence, offered post-abortion care at 29% of primary facilities. [ 2 ]


The  curative care  aspect of PAC includes treating incomplete abortions by removing any fetal or maternal tissues remaining in the uterus. This can include using  vacuum aspiration  (suction) or  curettage  (scraping). Aspiration results in shorter procedure times, less pain, and less blood loss than curettage. The drug  misoprostol  is an alternative to manual removal and is another option for treating incomplete abortion. [ 3 ]


For  preventative care , women are provided family planning counseling and services, as most women seeking PAC were not using modern contraceptives at the time of conception. A study in Zimbabwe found that family planning counseling was associated with a significant reduction in unwanted pregnancies and repeat abortions in the year after they received post-abortion care. Infrequently, sexual health screenings such as  HIV testing  are provided as part of post-abortion care, though  sexually transmitted infection  screening is low and has been identified as an unmet need of PAC. [ 3 ]


The term "post-abortion care" was first defined in the 1991 by the non-governmental organization (NGO)  Ipas . [ 4 ]  In 1993, Ipas joined  Jhpiego ,  EngenderHealth ,  Pathfinder International , and  International Planned Parenthood Federation , in creating the Postabortion Care Consortium. [ 5 ]


In 1994, a post-abortion care model was articulated by the Postabortion Care Consortium, with three key elements, regardless of the legality of abortion in a given country: 1) emergency treatment for abortion-related complications; 2) postabortion family planning counseling and services; and 3) linkage between emergency care and other reproductive health services, such as management of sexually transmitted diseases. [ 6 ]  The PAC model was adopted by  United States Agency for International Development  (USAID) in 1994. [ 3 ]  In 2002, two elements were added relating to counseling and community involvement. [ 7 ]  The first research compendium on post-abortion care was published in 2007 by USAID,  What Works, A Policy and Program Guide to the Evidence on Postabortion Care . [ 3 ]


Pregnancy options counseling  is a form of  counseling  that provides information and support regarding  pregnancy . Women seeking pregnancy options counseling are typically doing so in the case of an unplanned or  unintended pregnancy . Limited access to birth control and family planning resources, as well as misuse of birth control are some of the major contributing factors to unintended pregnancies around the world. In 2012, the global rate of unintended pregnancies was estimated to be 40 percent, or eighty-five million pregnancies. [ 1 ]


Pregnancy options counselors educate women about the different options that are available and help guide them to a decision on how to proceed with their pregnancy. The options include  abortion ,  adoption , or  parenting . The job of a pregnancy options counselor is to neither encourage nor discourage a woman's particular decision, nor do they profit from the woman's choice. [ 2 ]  Rather, they present unbiased information about each of the options non-judgmentally, then help the woman explore her feelings and come to a decision that fits her best based on her values, culture, future plans, etc. [ 3 ]  Pregnancy options counseling centers differ from  crisis pregnancy centers . [ 4 ]


One option that a woman with an unplanned pregnancy may consider is  abortion , the deliberate termination of a pregnancy. According to the World Health Organization (WHO), about 40–50 million abortions are performed worldwide each year. [ 5 ]  About 20 million of these abortions are considered unsafe and result in around 67,000 deaths each year. [ 6 ]  Abortion rates are similar across countries despite its being legal in some and illegal in others. In other words, just as many women get abortions in countries where it is illegal as in countries where it is legal. [ 7 ]  The only difference is that they proceed with illegal abortions, which are more likely to be provided under unsafe conditions by poorly trained providers. [ 6 ]  A woman's pregnancy options in regards to abortion would be presented differently by her counselor, depending on the country they are in. The  Mexico City Policy  is an example of governments restricting this aspect of pregnancy options counseling.


Adoption  is a permanent, legal transfer of parental rights and responsibilities from  child's birth parents to the adoptive parents. Pregnant women looking to place their child up for adoption might have options as to how much involvement they wish to have in choosing the adoptive parents, depending on the law in the jurisdiction where the adoption takes place. Some families may choose an  open adoption , which can allow the birth parents contact through phone calls, letters, or live meetings. Despite the name, open adoptions are not always enforceable, depending on the jurisdiction - adoptive parents may withdraw consent to contact at any point. Others may choose a  closed adoption , which does not allow the birth parents access to their child. [ 8 ]  Nonetheless, birthmothers choosing to put their child up for adoption are legally terminating their parental rights to the child. Adoption laws differ state by state; adoption agencies, counselors, and lawyers can be used to provide information to the birth parents and adoptive parents about this process. [ 9 ]


If a pregnant woman seeking pregnancy options counseling is considering completing her pregnancy, whether it be in the case of adoption or that she is choosing to parent, her next step would be to start  prenatal care , if available. [ 4 ]  Prenatal care is a type of  preventative healthcare  which serves to prevent potential health problems and promote a healthy lifestyle during the pregnancy. [ 10 ]


Some countries, such as Germany, legally require pregnancy options counselling before obtaining an abortion. [ 11 ]


Selective reduction  is the practice of reducing the number of  fetuses  in a  multiple pregnancy , such as  quadruplets , to a  twin  or singleton pregnancy. The procedure is also called  multifetal pregnancy reduction . [ 3 ]  The procedure is most commonly done to reduce the number of fetuses in a multiple pregnancy to a safe number, when the multiple pregnancy is the result of use of  assisted reproductive technology ; outcomes for both the mother and the babies are generally worse the higher the number of fetuses. [ 4 ]  The procedure is also used in multiple pregnancies when one of the fetuses has a serious and incurable disease, or in the case where one of the fetuses is  outside the uterus , in which case it is called  selective termination . [ 4 ]


The procedure generally takes two days; the first day for testing to select which fetuses to reduce, and the 2nd day for the procedure itself, in which  potassium chloride  is injected into the heart of each selected fetus under the guidance of ultrasound imaging. [ 5 ]   Risks of the procedure include bleeding requiring transfusion, rupture of the uterus,  retained placenta , infection, a miscarriage, and  prelabor rupture of membranes . Each of these appears to be rare. [ 4 ]


Selective reduction was developed in the mid-1980s, as people in the field of assisted reproductive technology became aware of the risks that multiple pregnancies carried for the mother and for the fetuses. [ 6 ] [ 7 ]


Selective reduction is used when a mother is carrying an unsafe or undesirable number of fetuses in a  multiple pregnancy , which are common in  medically assisted pregnancies . The result is a reduction in the number of fetuses to a number that is more safe for the mother and the remaining fetuses or more compatible with socio-economic constraints on the caregivers. [ 3 ] [ 8 ] [ 5 ]  It is also used in cases of multiple pregnancy where at least one of the fetuses is  implanted outside the uterus  to preserve the life of the mother and the fetus in the uterus, [ 9 ]  and when one or more of the fetuses has a serious and incurable disease. [ 4 ]  One example of is  TRAP  syndrome, where one fetus lacks a heart; the second twin, termed a "pump" twin therefore supplies the second twin with blood, leading to heart failure and death in the second twin in 50-75% of cases if the acardiac twin is not terminated. [ 10 ]


While the data is weak, due to the small sizes of studies and the lack of randomized controlled trials, as of 2017 it appeared that when short term perinatal outcomes in multiple pregnancies reduced to twins are compared to those of non-reduced triplets, there were fewer deaths among the babies born to mothers who underwent reduction, the twins were born later and were less likely to be  premature , and had higher birthweight. [ 8 ]  As of 2017, longterm outcomes were not well understood. [ 8 ]  A 2015 Cochrane review found no randomized clinical trials to evaluate. [ 11 ]


Generally selective reduction reduces the risk of preterm birth, leading to better outcomes for both mothers and the newborns. [ 12 ]


It appears that reduction of triplets, where each triplet is in its own placenta, to twins results in a lower risk of preterm birth and does not increase the risk of miscarriage. In triplets where two of the fetuses share a placenta and each has its own amniotic sac, it appears, with less certainty, that there is also a lower risk of preterm birth and no increase in the risk of miscarriage. [ 2 ]


Risks of the procedure include bleeding requiring transfusion, rupture of the uterus,  retained placenta , infection, a miscarriage, and  prelabor rupture of membranes . Each of these appears to be rare. [ 4 ]


The reduction procedure is generally carried out during the first trimester of pregnancy.  The procedure often takes two days; the first day is for testing, and the procedure happens on the second day. The fetuses are evaluated, first by  ultrasound , then often by  testing the amniotic fluid  and  chorionic villus sampling ; these tests help determine which fetuses are accessible for the procedure, and whether any fetuses are unhealthy. Once the specific fetuses to be reduced are identified,  potassium chloride  is injected into the heart of each selected fetus under the guidance of ultrasound imaging; the heart stops and the fetus dies as a result. Generally, the fetal material is reabsorbed into the woman's body. [ 5 ]


Selective reduction was developed in the mid-1980s, as people in the field of  assisted reproductive technology  (ART) became aware of the risks that multiple pregnancies carried for the mother and for the fetuses. [ 6 ] [ 7 ]   The procedure was somewhat controversial from the beginning and drew some attention from anti-abortion activists. [ 7 ]


A set of ethical guidelines was developed in collaboration with a bioethicist from the  National Institute for Health  and was published in 1988; it justified reducing pregnancies with more than three fetuses to two or three. [ 7 ] [ 13 ]


Over time, more and more women in the developed world sought to become pregnant when they were older, having the first child when they were over forty years old. At the same time, the number of obstetrician-gynecologists with the required expertise increased and their role in family planning evolved. These trends led to more women asking for reduction to one fetus. These requests increasingly came from women pregnant with twins due to advances in the field of ART which made massively multiple pregnancies rarer. Selective reduction of twins was very controversial at first but has gradually become more accepted. One of the authors of the 1988 guidelines updated his stance and expressed a desire for the procedure to become more available in 2014.  Sex-selective reduction  is widely considered to be unethical in making decisions about which fetus to keep. [ 3 ] [ 5 ] [ 7 ]


A  self-induced abortion  (also called a  self-managed abortion , or sometimes a  self-induced miscarriage ) is an  abortion  performed by the pregnant woman herself, or with the help of other, non-medical assistance. Although the term includes abortions induced outside of a clinical setting with legal, sometimes  over-the-counter medication , it also refers to efforts to terminate a pregnancy through alternative, potentially more dangerous methods. [ 1 ]  Such practices may present a threat to the health of women. [ 2 ]


Self-induced (or self-managed) abortion is often attempted during the beginning of pregnancy (the first eight weeks from the last  menstrual period ). [ 3 ] [ 4 ]  In recent years, significant reductions in  maternal death  and injury resulting from self-induced abortions have been attributed to the increasing availability of  misoprostol  (known commercially as "Cytotec"). [ 5 ] [ 6 ]  This medication is a synthetic  prostaglandin E1  that is inexpensive, widely available, and has multiple uses, including the treatment of  post-partum hemorrhage ,  stomach ulcers ,  cervical preparation  and  induction of labor . [ 7 ]  The  World Health Organization  (WHO) has endorsed two regimens for abortion up to 12 weeks of pregnancy using misoprostol: a standardized regimen of mifepristone and misoprostol and a regimen of misoprostol alone. [ 8 ]  The regimen with misoprostol alone has been shown to be up to 83% effective in terminating a pregnancy but is more effective combined with mifepristone. [ 9 ]


Women can use many different methods to self-manage (or self-induce) an abortion. [ 10 ]  Some are safe and effective, while others are dangerous to the health of the woman and/or ineffective at terminating a pregnancy.


The only scientifically studied effective self-induced abortion method is ingesting a combination of  mifepristone  and  misoprostol  or misoprostol alone. [ 8 ]  The combination of these medications is on the  World Health Organization's List of Essential Medicines . [ 11 ]  In some countries, these pills may be available over-the-counter in pharmacies, although some pharmacies do not provide accurate instructions on use. [ 12 ]  In Latin America, women have reported self-inducing abortions with misoprostol alone since the 1980s. [ 13 ]  The history of women self-managing abortion with pills includes projects such as the Socorristas in Argentina and Las Libres in Mexico. [ 14 ] [ 15 ]  Other countries have "safe abortion hotlines", which facilitate access to pills, provide instructions on proper use of the pills, and provide emotional, logistical, and/or financial support. [ 16 ] [ 17 ]  Some women use online abortion pill help services such as  Women on Web  and  Aid Access  to order mifepristone and/or misoprostol, with reported effectiveness and safety in pregnancy termination and satisfaction in the service. [ 18 ] [ 19 ]  Instructions on abortion pill use are widely available on the websites of the  World Health Organization  (WHO), Gynuity Health Projects, [ 9 ]  and the International Women's Health Coalition. [ 20 ]


First trimester medical abortion is highly safe and effective. [ 21 ]  The side effects of medication abortion include uterine cramping and prolonged bleeding, and common side effects include nausea, vomiting and  diarrhea . The majority of women who use abortion pills on their own do not need an ultrasound or a clinician, although one may be recommended to ensure that the pregnancy is not  ectopic . [ 18 ]  In the rare case of a complication, a woman can access a clinician skilled in miscarriage management, which is available in all countries. [ 19 ]


Studies confirm a correlation between the increase in the self-administration of medical abortion with misoprostol, and a reduction in  maternal morbidity  and mortality. [ 22 ]  Some studies argue that unfettered access to medication abortion is a key tenet of public health, human rights, and reproductive rights. [ 23 ]


Self-induced abortion methods vary around the world. The most commonly recorded are ingestion of plants or herbs, ingesting toxic substances, causing trauma to the  uterus , causing physical trauma to the body, using  alcohol  and drugs in an attempt to end the pregnancy, and ingesting other substances and mixtures. [ 25 ]  There are no known effectiveness studies for plants, herbs, drugs, alcohol, or other substances. These methods are more likely to cause bodily harm to the pregnant woman than to be effective in terminating a pregnancy. Causing physical trauma to a woman's body or uterus may also result in physical harm or even death to the woman instead of causing an abortion. [ 22 ]


A  descriptive study  of women seeking to induce abortion in Cape Town, South Africa found that the women used abortifacients from three major sources: traditional healers, illegal abortion providers, and home remedies prepared using over-the-counter ingredients. The abortifacients included assorted pills (some that were likely misoprostol, others included  antiviral drugs ,  hypertension  medication, and  izifozonke ), herbal blends of unclear origin, commercial herbal blends (including  Stametta ), "Dutch remedies" (including  Vornokroy ,  Helmin  drops, and  potassium permanganate ), abrasive substances, alcohol, bleach, ammonia, other household cleaners, and laxatives. [ 26 ]


As of 2019 [update] , an estimated 56 million abortions occurred worldwide, of which 25 million are considered by the WHO to be less safe or least safe. [ 27 ]  Induced abortion is considered safe when WHO recommended methods are used by trained persons, less safe when only one of those two criteria is met, and least safe when neither is met. [ 28 ]  Self-induced abortions can be safe or unsafe depending on the methods used. [ 29 ] [ 30 ]


It is difficult to measure the prevalence or rate of self-induced abortions. As of 2018 [update] , in the United States, the estimate was that one in 10 abortions is self-induced. [ 31 ]  While maternal morbidity and mortality from unsafe abortion has continued to increase due to population growth, in Latin America, from 2005 to 2012, there was a 31% decrease in the number of complications from unsafe abortion, from 7.7/1,000 to 5.3/1,000. Researchers believe that this may be due to the wide availability of misoprostol in Latin America. [ 32 ]  In late 2019, it was reported that rates of self-induced abortion in the United States were rising, partly due to fears that more conservative policies would limit access to clinical abortion, and partly due to the increased availability and convenience of  telehealth  medical supervision and prescriptions and mail-order drugs. [ 33 ]


The practice of attempted self-induced abortion has long been recorded in the United States. Turn-of-the-20th-century  birth control  advocate  Margaret Sanger  wrote in her autobiography of a 1912 incident in which she was summoned to treat a woman who had nearly died from such an attempt. [ 34 ]


In a letter to  The New York Times , gynecologist Waldo L. Fielding wrote:


The familiar symbol of illegal abortion is the infamous "coat hanger" — which may be the symbol, but is in no way a myth. In my years in New York, several women arrived with a hanger still in place. Whoever put it in – perhaps the patient herself – found it trapped in the cervix and could not remove it...However, not simply coat hangers were used. Almost any implement you can imagine had been and was used to start an abortion – darning needles, crochet hooks, cut-glass salt shakers, soda bottles, sometimes intact, sometimes with the top broken off. [ 35 ]


Charles Jewett wrote  The Practice of Obstetrics  in 1901. In it, he stated, "Oil of tansy and oil of rue are much relied on by the laity for the production of abortion, and almost every day one may read of fatal results attending their use. Oil of tansy in large doses is said to excite epileptiform convulsions; quite recently one of my colleagues met such a case in his practice."


In the 1994 documentary  Motherless: A Legacy of Loss from Illegal Abortion , Louis Gerstley, M.D., said that, in addition to knitting needles, some women would use the spokes of bicycle wheels or umbrellas. "Anything that was metal and long and thin would be used," he stated. He stated that a common complication from such a procedure was that the object would puncture through the uterus and injure the intestines, and the women would subsequently die from  peritonitis  and infection. Later in the film, he mentioned that  potassium permanganate  tablets were sometimes used. The tablets were inserted into the vagina where they caused a chemical burn so intense that a hole may be left in the tissue. He claimed the tablets left the surrounding tissue in such a state that doctors trying to stitch up the wound couldn't do so because "the tissue was like trying to suture butter." Dr. Mildred Hanson also described the use of potassium permanganate tablets in the 2003 documentary  Voices of Choice: Physicians Who Provided Abortions Before Roe v. Wade . She said, "the women would bleed like crazy because it would just eat big holes in the vagina."


Dr.  David Reuben  mentions that many African women use a carved wooden "abortion stick" to induce, which has often been handed down. [ 36 ]


A study concluded in 1968 [ 37 ]  determined that over 500,000 illegal abortions were performed every year in the United States, a portion of which were performed by women acting alone. The study suggested that the number of women dying as a result of self-induced abortions exceeded those resulting from abortions performed by another person. A 1979 study noted that many women who required hospitalization following self-induced abortion attempts were admitted under the pretext of having had a  miscarriage  or  spontaneous abortion . [ 38 ]


WHO estimates that approximately 25 million abortions continue to be performed unsafely each year. [ 28 ]  Around 7 million women are admitted to hospitals every year in developing countries [ 39 ]  and between 4.7% – 13.2% of all maternal deaths can be attributed to unsafe abortion. [ 40 ]  Almost every one of these deaths and disabilities could have been prevented through sexual education, family planning, and the provision of safe abortion services. [ 2 ]  Abortion pills, which were first used by Brazilian women in the 1980s, can prevent many of these deaths from unsafe abortion. [ 41 ]


While positions regarding  abortion in Islam  is one open to varied interpretation by Muslim scholars, in  Iran , self-induced abortion, as with other forms of abortion in general, is considered to be a  haram  act, in accordance a declaration by  Ayatollah Khomeini  that all forms of abortion are forbidden, mirroring a common position held under Shi'ite interpretation of  Sharia law . As a result, a  diyya  of approximately 1000  dinar  is issued for the abortion of male fetuses and half of that amount for female ones, though the  diyya  is lowered to 60 dinar, the parent must pay the diyya to child's kin [ clarification needed ] . [ 42 ] [ 43 ] [ 44 ]


In the United States, experts report that self-induced abortion can be medically safe but legally risky. [ 45 ]  The 1973 Supreme Court decision  Roe v. Wade , which was overturned in the 2022 case  Dobbs v. Jackson Women's Health Organization , made abortion more readily available throughout the U.S., yet women who have abortions with pills ordered online or through non-clinical means may face risk of arrest. [ 46 ] [ 47 ]


It is not common for women in the United States to be charged for the crime of self-inducing an abortion. However, a small number of people in the U.S. have been arrested for ending their own pregnancies with pills ordered online, including  Purvi Patel , Jennie Linn McCormack, [ 48 ]  and Kenlissia Jones. [ 49 ] [ 50 ]  These women were prosecuted under a variety of laws including laws directly criminalizing self-induced abortions, laws criminalizing harm to fetuses, criminal abortion laws misapplied to people who self-induce, and various laws deployed when no other legal authorization could be found. [ 51 ]  In 2022, Lizelle Herrera of Texas was charged with murder after the authorities alleged that she caused "the death of an individual by self-induced abortion". [ 52 ]  It was unclear whether she had an abortion herself or helped someone else with it. According to  University of Texas  law professor  Stephen Vladeck , the state law exempts the mother from criminal homicide charges for aborting her own child. [ 53 ]  On 10 April 2022, the district attorney of Texas announced that the murder charges would be dismissed. [ 54 ]


As of 2019, there are seven states with laws directly criminalizing self-induced abortion, 11 states with laws criminalizing harm to fetuses that lack adequate exemptions for the pregnant woman, and 15 states with criminal abortion laws that could be applied to women who self-induce an abortion. [ 55 ]  Both the  National Lawyers Guild  and the  American Medical Association  passed resolutions condemning the criminalization of self-induced abortion. [ 56 ] [ 57 ]


Sex-selective abortion  is the practice of terminating a pregnancy based upon the predicted sex of the infant. The selective  abortion  of female fetuses is most common where male children are valued over female children, especially in parts of  East Asia  and  South Asia  (particularly in countries such as  People's Republic of China ,  India  and  Pakistan ), as well as in the  Caucasus ,  Western Balkans , and to a lesser extent  North America . [ 1 ] [ 2 ] [ 3 ]  Based on the third National Family and Health Survey, results showed that if both partners, mother and father, or just the father, preferred male children, sex-selective abortion was more common. In cases where only the mother prefers sons, this is likely to result in sex-selective neglect in which the child is not likely to survive past infancy. [ 4 ]


Sex-selective abortion was first documented in 1975, [ 5 ]  and became commonplace by the late 1980s in  South Korea  and China and around the same time or slightly later in India.


Sex-selective abortion affects the  human sex ratio —the relative number of males to females in a given age group, [ 6 ] [ 7 ]  with China and India, the two  most populous countries  of the world, having unbalanced gender ratios. Studies and reports focusing on sex-selective abortion are predominantly statistical; they assume that birth-sex ratio—the overall ratio of boys and girls at birth—for a regional population is an indicator of sex-selective abortion. This assumption has been questioned by some scholars. [ 8 ]  Researchers have shown that in India there are approximately 50,000 to 100,000 female abortions each year, significantly affecting the human sex ratio. [ 9 ]


Recent studies have expanded the understanding of this issue by quantifying trends in conditional sex ratios (CSRs) among Asian diaspora populations in Australia, Canada, the UK, and the US, showing that sex selection practices have persisted among diaspora communities from 1999 to 2019. [ 10 ]  Research into the past four decades of sex-selective abortions in China highlights the significant role these practices have played in shaping the country's demographic profile, despite challenges in estimating exact numbers due to underreporting and the controversial level of sex ratio at birth (SRB). [ 11 ]


According to demographic scholarship, the expected birth-sex ratio range is 103 to 107 males to 100 females at birth. [ 12 ] [ 13 ] [ 14 ]


Sex-selective abortion affects the  human sex ratio —the relative number of males to females in a given age group. [ 6 ]  Studies and reports that discuss sex-selective abortion are based on the assumption that birth sex ratio—the overall ratio of boys and girls at birth for a regional population, is an indicator of sex-selective abortion. [ 8 ] [ 15 ]


The natural human sex ratio at birth was estimated, in a 2002 study, to be close to 106 boys to 100 girls. [ 16 ]  Human sex ratio at birth that is significantly different from 106 is often assumed to be correlated to the prevalence and scale of sex-selective abortion. Countries considered to have significant practices of sex-selective abortion are those with birth sex ratios of 108 and above (selective abortion of females), and 102 and below (selective abortion of males). [ 12 ]  This assumption is controversial, and the subject of continuing scientific studies.


One school of scholars suggest that any birth sex ratio of boys to girls that is outside of the normal 105–107 range, necessarily implies sex-selective abortion. These scholars [ 17 ]  claim that both the sex ratio at birth and the population sex ratio are remarkably constant in human populations. Significant deviations in birth sex ratios from the normal range can only be explained by manipulation, that is sex-selective abortion. [ 18 ]


In a widely cited article, [ 19 ]   Amartya Sen  compared the birth sex ratio in Europe (106) and the United States (105) with those in Asia (107+) and argued that the high sex ratios in East Asia, West Asia and South Asia may be due to excessive female mortality. Sen pointed to research that had shown that if men and women receive similar nutritional and medical attention and good health care then females have better survival rates, and it is the male which is the genetically fragile sex. [ 13 ]


Sen estimated  'missing women' from extra women who would have survived in Asia  if it had the same ratio of women to men as Europe and the United States. According to Sen, the high birth sex ratio over decades implies a female shortfall of 11% in Asia, or over 100 million women as missing from the 3 billion combined population of South Asia, West Asia, North Africa and China.


Other scholars question whether birth sex ratio outside 103–107 can be due to natural reasons. William James and others [ 8 ] [ 20 ] [ 21 ] [ 22 ] [ 23 ]  suggest that conventional assumptions have been:


James cautions that available scientific evidence stands against the above assumptions and conclusions. He reports that there is an excess of males at birth in almost all human populations, and the natural sex ratio at birth is usually between 102 and 108. However the ratio may deviate significantly from this range for natural reasons such as early marriage and fertility, teenage mothers, average maternal age at birth, paternal age, age gap between father and mother, late births, ethnicity, social and economic stress, warfare, environmental and hormonal effects. [ 8 ] [ 24 ]  This school of scholars support their alternate hypothesis with historical data when modern sex-selection technologies were unavailable, as well as birth sex ratio in sub-regions, and various ethnic groups of developed economies. [ 25 ] [ 26 ]  They suggest that direct abortion data should be collected and studied, instead of drawing conclusions indirectly from human sex ratio at birth.


James' hypothesis is supported by historical birth sex ratio data before technologies for ultrasonographic sex-screening were discovered and commercialized in the 1960s and 1970s, as well by reverse abnormal sex ratios currently observed in Africa. Michel Garenne reports that many African nations have, over decades, witnessed birth sex ratios below 100, that is more girls are born than boys. [ 27 ]   Angola ,  Botswana  and  Namibia  have reported birth sex ratios between 94 and 99, which is quite different from the presumed 104 to 106 as natural human birth sex ratio. [ 27 ] : 95


John Graunt  noted that in London over a 35-year period in the 17th century (1628–62), [ 28 ]  the birth sex ratio was 1.07; while Korea's historical records suggest a birth sex ratio of 1.13, based on 5 million births, in 1920s over a 10-year period. [ 29 ]  Other historical records from Asia too support James' hypothesis. For example, Jiang et al. claim that the birth sex ratio in China was 116–121 over a 100-year period in the late 18th and early 19th centuries; in the 120–123 range in the early 20th century; falling to 112 in the 1930s. [ 30 ] [ 31 ]


In the United States, the sex ratios at birth over the period 1970–2002 were 105 for the white non-Hispanic population, 104 for Mexican Americans, 103 for African Americans and Native Americans, and 107 for mothers of Chinese or Filipino ethnicity. [ 32 ] [ 33 ] [ 34 ]  In the aggregated results of 56 Demographic and Health Surveys [ 35 ]  in African countries, the birth sex ratio was found to be 103, though there is also considerable country-to-country, and year-to-year variation. [ 36 ]


In a 2005 study, U.S. Department of Health and Human Services reported sex ratio at birth in the United States from 1940 over 62 years. [ 32 ]  This statistical evidence suggested the following: For mothers having their first baby, the total sex ratio at birth was 106 overall, with some years at 107. For mothers having babies after the first, this ratio consistently decreased with each additional baby from 106 towards 103. The age of the mother affected the ratio: the overall ratio was 105 for mothers aged 25 to 35 at the time of birth; while mothers who were below the age of 15 or above 40 had babies with a sex ratio ranging between 94 and 111, and a total sex ratio of 104. This United States study also noted that American mothers of Hawaiian, Filipino, Chinese, Cuban and Japanese ethnicity had the highest sex ratio, with years as high as 114 and average sex ratio of 107 over the 62-year study period. Outside of United States, European nations with extensive birth records, such as Finland, report similar variations in birth sex ratios over a 250-year period, that is from 1751 to 1997 AD. [ 26 ]


Female Selective abortions in Asia are predominantly practiced in areas such as Taiwan, China, and India. The Sex ratio at birth in Asia based on worldwide data is 104 and 107 males per 100 females, which was the accepted norm before sex selective abortion was available. Unfortunately, census results from 2000 are still being reviewed and currently unavailable. [ 37 ]


In 2017, according to CIA estimates, [ 38 ]  the countries with the highest birth sex ratio were  Liechtenstein  (125),  Northern Mariana Islands  (116),  China  (114),  Armenia  (112),  Falkland Islands  (112),  India  (112),  Grenada  (110),  Hong Kong  (110),  Vietnam  (110),  Albania  (109),  Azerbaijan  (109),  San Marino  (109),  Isle of Man  (108),  Kosovo  (108) and  Macedonia  (108). Also in 2017 the lowest ratio (i.e. more girls born) was in  Nauru  at 83. [ 38 ]  There were ratios of 102 and below in several countries, most of them African countries or Black/African majority population Caribbean countries: Angola, Aruba, Barbados, Bermuda, Burkina Faso, Burundi, Cabo Verde, Cameroon, Cayman Islands, Central African Republic, Chad, Comoros, Republic of the Congo, Côte d'Ivoire, Djibouti, Eritrea, Eswatini, Ethiopia, Gabon, The Gambia, Ghana, Guinea-Bissau, Haiti, Kazakhstan, Lesotho, Liberia, Madagascar, Malawi, Mali, Mauritania, Mozambique, Niger, Puerto Rico, Qatar, Senegal, Sierra Leone, Somalia, South Africa, Togo, Uganda, Zambia. [ 38 ]


There is controversy about the notion of the exact natural sex ratio at birth. In a study around 2002, the natural sex ratio at birth was estimated to be close to 1.06 males/female. [ 16 ]  There is controversy whether sex ratios outside the 103-107 range are due to sex-selection, as suggested by some scholars, or due to natural causes. The claims that unbalanced sex ratios are necessary due to sex selection have been questioned by some researchers. [ 8 ]  Some researchers argue that an unbalanced sex ratio should not be automatically held as evidence of prenatal sex-selection; Michel Garenne reports that many African nations have, over decades, witnessed birth sex ratios below 100, that is more girls are born than boys. [ 27 ]  Angola, Botswana and Namibia have reported birth sex ratios between 94 and 99, which is quite different than the presumed "normal" sex ratio, meaning that significantly more girls have been born in such societies. [ 27 ] : 95


In addition, in many developing countries there are problems with  birth registration  and data collection, which can complicate the issue. [ 39 ]  With regard to the prevalence of sex selection, the media and international attention has focused mainly on a few countries, such as China, India and the  Caucasus , ignoring other countries with a significant sex imbalance at birth. For example,  Liechtenstein 's sex ratio is far worse than that of those countries, but little has been discussed about it, and virtually no suggestions have been made that it may practice sex selection, although it is a very conservative country where  women could not vote until 1984 . [ 40 ] [ 41 ]  At the same time, there have been accusations that the situation in some countries, such as  Georgia , has been exaggerated. [ 42 ]  In 2017, Georgia' sex ratio at birth was 107, according to CIA statistics. [ 43 ]


The estimates for birth sex ratios, and thus derived sex-selective abortion, are a subject of dispute as well. For example, United States' CIA projects [ 44 ]  the birth sex ratio for  Switzerland  to be 106, while the Switzerland's Federal Statistical Office that tracks actual live births of boys and girls every year, reports the latest birth sex ratio for Switzerland as 107. [ 45 ]  Other variations are more significant; for example, CIA projects [ 44 ]  the birth sex ratio for  Pakistan  to be 105, United Nations FPA office claims [ 46 ]  the birth sex ratio for Pakistan to be 110, while the government of Pakistan claims its average birth sex ratio is 111. [ 47 ] [ 48 ] [ 49 ]


The two most studied nations with high sex ratio and sex-selective abortion are China and India. The CIA estimates [ 44 ]  a birth sex ratio of 112 for both in recent years. However, The World Bank claims the birth sex ratio for China in 2009 was 120 boys for every 100 girls; [ 50 ]  while United Nations FPA estimates China's 2011 birth sex ratio to be 118. [ 51 ]


For India, the United Nations FPA claims a birth sex ratio of 111 over 2008–10 period, [ 51 ]  while The World Bank and India's official 2011 Census reports a birth sex ratio of 108. [ 52 ] [ 53 ]  These variations and data reliability is important as a rise from 108 to 109 for India, or 117 to 118 for China, each with large populations, represent a possible sex-selective abortion of about 100,000 girls.


Bias is due to the unreported births in hospitals which makes a slight difference on the data they report vs the census. If parents obtain sex testing before birth, and abortion was made and it was based on female fetus, it is more likely for the abortion to happen in the hospital for safety purposes and would have been reported. With no comparative data with hospitals vs nonhospital births the length of biased would be unable to determine opposed to those countries where most hospital births occur and are actually reported. [ 37 ]


The earliest post-implantation test,  cell free fetal DNA  testing, involves taking a blood sample from the mother and isolating the small amount of fetal  DNA  that can be found within it. When performed after week seven of pregnancy, this method is about 98% accurate. [ 54 ] [ 55 ]


Obstetric ultrasonography , either transvaginally or transabdominally, checks for various markers of fetal sex. It can be performed at or after week 12 of pregnancy. At this point,  3 ⁄ 4  of fetal sexes can be correctly determined, according to a 2001 study. [ 56 ]  Accuracy for males is approximately 50% and for females almost 100%. When performed after week 13 of pregnancy, ultrasonography gives an accurate result in almost 100% of cases. [ 56 ]


The most invasive measures are  chorionic villus sampling  (CVS) and  amniocentesis , which involve testing of the chorionic villus (found in the placenta) and  amniotic fluid , respectively. Both techniques typically test for  chromosomal disorders  but can also reveal the sex of the child and are performed early in the pregnancy. However, they are often more expensive and more dangerous than blood sampling or ultrasonography, so they are seen less frequently than other sex determination techniques. [ 57 ]


Prenatal sex determination is restricted in many countries, and so is the communication of the sex of the fetus to the pregnant woman or her family, in order to prevent sex selective abortion.
In India, prenatal sex determination is regulated under the  Pre-conception and Prenatal Diagnostic Techniques (Prohibition of Sex Selection) Act  1994. [ 58 ]


China launched its first ultrasonography machine in 1979. [ 15 ]  Chinese health care clinics began introducing ultrasound technologies that could be used to determine prenatal sex in 1982. By 1991, Chinese companies were producing 5,000 ultrasonography machines per year. Almost every rural and urban hospital and family planning clinics in China had a good quality sex discernment equipment by 2001. [ 15 ]


The launch of ultrasonography technology in India too occurred in 1979, but its expansion was slower than China. Ultrasound sex discernment technologies were first introduced in major cities of India in the 1980s, its use expanded in India's urban regions in the 1990s, and became widespread in the 2000s. [ 59 ]


Sex selective abortion based on son preference is significant in  North Africa  and the  Middle East . [ 60 ] [ 61 ] [ 39 ]


The total numbers of "missing women" are about 11.9 million and 10.6 million in  China  and  India  respectively, out of 23 million world-wide, according to a 2019 study. [ 14 ]  Given that the total number of recorded abortions is much lower than that, some dispute those numbers.


China, the most populous country in the world, has a serious problem with an unbalanced sex ratio population. A 2010 BBC article stated that the sex birth ratio was 119 boys born per 100 girls, which rose to 130 boys per 100 girls in some rural areas. [ 62 ]  The Chinese Academy of Social Sciences estimated that more than 24 million Chinese men of marrying age could find themselves without spouses by 2020. [ 62 ]  In 1979, China enacted the  one-child policy , which, within the country's deeply patriarchal culture, resulted in an unbalanced birth sex ratio. The one child policy was enforced throughout the years, including through  forced abortions  and  forced sterilizations , but gradually loosened until it was formally abolished in 2015. [ 63 ]


When sex ratio began being studied in China in 1960, it was still within the normal range. However, it climbed to 111.9 by 1990 [ 15 ]  and to 118 by 2010 per its official census. [ 64 ] [ 65 ]  Researchers believe that the causes of this sex ratio imbalance are increased female infant mortality, underreporting of female births and sex-selective abortion. According to Zeng et al. (1993), the most prominent cause is probably sex-selective abortion, but this is difficult to prove that in a country with little reliable birth data because of the hiding of "illegal" (under the One-Child Policy) births. [ 66 ]


These illegal births have led to underreporting of female infants. Zeng et al., using a reverse survival method, estimate that underreporting keeps about 2.26% male births and 5.94% female births off the books. Adjusting for unreported illegal births, they conclude that the corrected Chinese sex ratio at birth for 1989 was 111 rather than 115. [ 66 ]  These national averages over time, mask the regional sex ratio data. For example, in 2005  Anhui ,  Jiangxi ,  Shaanxi ,  Hunan  and  Guangdong , had a sex ratio at birth of more than 130. [ 67 ] [ 68 ]


Traditional Chinese techniques have been used to determine sex for hundreds of years, primarily with unknown accuracy. It was not until  ultrasonography  became widely available in urban and rural China that sex was able to be determined scientifically. In 1986, the Ministry of Health posted the Notice on Forbidding Prenatal Sex Determination, but it was not widely followed. [ 69 ]  Three years later, the Ministry of Health outlawed the use of sex determination techniques, except for in diagnosing hereditary diseases. [ 70 ]  Individuals or clinics that violated the ban on prenatal determination at the request of the mother were subject to financial penalties, and the ban was repeatedly affirmed in the 1980s, early 1990s, and early 2000s. [ 71 ]  However, many people have personal connections to medical practitioners and strong  son preference  still dominates culture, leading to the widespread use of sex determination techniques. [ 15 ]


Hardy, Gu, and Xie suggest sex-selective abortion is more prevalent in rural China because son preference is much stronger there. [ 72 ]  Urban areas of China, on average, are moving toward greater equality for both sexes, while rural China tends to follow more traditional views of gender. This is partially due to the belief that, while sons are always part of the family, daughters are only temporary, going to a new family when they marry. Additionally, if a woman's firstborn child is a son, her position in society moves up, while the same is not true of a firstborn daughter. [ 15 ]  Families in China are aware of the critical lack of female children and its implication on marriage prospects in the future; many parents are beginning to work extra when their sons are young so that they will be able to pay for a bride for them. [ 15 ]


In a 2005 study, Zhu, Lu, and Hesketh found that the highest sex ratio was for those ages 1–4, and two provinces, Tibet and Xinjiang, had sex ratios within normal limits. Two other provinces had a ratio over 140, four had ratios between 130 and 139, and seven had ratios between 120 and 129, each of which is significantly higher than the natural sex ratio. [ 68 ]


The birth sex ratio in China, according to a 2012 news report, has decreased to 117 males born for every 100 females. [ 73 ]  The sex ratio peaked in 2004 at around 121, and had declined to around 112 in 2017. [ 74 ]  The ratio was forecast to drop below 112 by 2020 and 107 by 2030, according to the National Population Development Outline by the State Council. [ 75 ]


In December 2016, researchers at the  University of Kansas  reported that the missing women might be largely a result of administrative under-reporting and that delayed registration of females, instead of abortion and  infanticide  practices. The finding questioned the earlier assumptions that rural Chinese villagers aborted their daughters on a massive scale and concluded that as many as 10 to 15 million missing women hadn't received proper birth registration since 1982. [ 76 ] [ 77 ]  The reason for underreporting was attributed to families trying to avoid penalties when girls were born, and local government concealing the lack of enforcement from the central government. This implied that the sex disparity of the Chinese newborns was likely exaggerated significantly in previous analyses. [ 78 ] [ 79 ] [ 80 ]  Though the degree of data discrepancy, the challenge in relation to sex-ratio imbalance in China is still disputed among scholars. [ 81 ] [ 82 ]


A research by  Pew Research Center  based on Union government data indicates foeticide of at least 9 million females in the years 2000–2019. The research found that 86.7% of these foeticides were by  Hindus  (80% of the population), followed by  Sikhs  (1.7% of the population) with 4.9%, and  Muslims  (14% of the population) with 6.6%. The research also indicated an overall decline in preference for sons in the time period. [ 83 ]


India's 2001 census revealed a national 0–6 age child sex ratio of 108, which increased to 109 according to 2011 census (927 girls per 1000 boys and 919 girls per 1000 boys respectively, compared to expected normal ratio of 943 girls per 1000 boys). [ 84 ] [ 85 ]  The national average masks the variations in regional numbers according to 2011 census—Haryana's ratio was 120, Punjab's ratio was 118, Jammu & Kashmir was 116, and Gujarat's ratio was 111. [ 86 ]  The 2011 Census found eastern states of India had birth sex ratios between 103 and 104, lower than normal. [ 87 ]  In contrast to decadal nationwide census data, small non-random sample surveys report higher child sex ratios in India. [ 88 ]


The child sex ratio in India shows a regional pattern. India's 2011 census found that all eastern and southern states of India had a child sex ratio between 103 and 107, [ 86 ]  typically considered as the "natural ratio." The highest sex ratios were observed in India's northern and northwestern states –  Haryana  (120),  Punjab  (118) and  Jammu & Kashmir  (116). [ 89 ]  The western states of Maharashtra and Rajasthan 2011 census found a child sex ratio of 113, Gujarat at 112 and Uttar Pradesh at 111. [ 89 ]


The Indian census data suggests there is a positive correlation between abnormal sex ratio and better socio-economic status and literacy. Urban India has higher child sex ratio than rural India according to 1991, 2001 and 2011 Census data, implying higher prevalence of sex selective abortion in urban India. Similarly, child sex ratio greater than 115 boys per 100 girls is found in regions where the predominant majority is Hindu, Muslim, Sikh or Christian; furthermore "normal" child sex ratio of 104 to 106 boys per 100 girls are also found in regions where the predominant majority is Hindu, Muslim, Sikh or Christian. These data contradict any hypotheses that may suggest that sex selection is an archaic practice which takes place among uneducated, poor sections or particular religion of the Indian society. [ 86 ] [ 90 ]


Rutherford and Roy, in their 2003 paper, suggest that techniques for determining sex prenatally that were pioneered in the 1970s, gained popularity in India. [ 91 ]  These techniques, claim Rutherford and Roy, became broadly available in 17 of 29 Indian states by the early 2000s. Such prenatal sex determination techniques, claim Sudha and Rajan in a 1999 report, where available, favored male births. [ 92 ]


Arnold, Kishor, and Roy, in their 2002 paper, too hypothesize that modern fetal sex screening techniques have skewed child sex ratios in India. [ 93 ]  Ganatra et al., in their 2000 paper, use a small survey sample to estimate that  1 ⁄ 6  of reported abortions followed a sex determination test. [ 94 ]


The Indian government and various advocacy groups have continued the debate and discussion about ways to prevent sex selection. The immorality of prenatal sex selection has been questioned, with some arguments in favor of prenatal discrimination as more humane than postnatal discrimination by a family that does not want a female child. Others question whether the morality of sex selective abortion is any different over morality of abortion when there is no risk to the mother nor to the fetus, and abortion is used as a means to end an unwanted pregnancy. [ 95 ] [ 96 ] [ 97 ]


India passed its first abortion-related law, the so-called Medical Termination of Pregnancy Act of 1971, making abortion legal in most states, but specified legally acceptable reasons for abortion such as medical risk to mother and rape. The law also established physicians who can legally provide the procedure and the facilities where abortions can be performed, but did not anticipate sex selective abortion based on technology advances. [ 98 ]


With increasing availability of sex screening technologies in India through the 1980s in urban India, and claims of its misuse, the Government of India passed the  Pre-natal Diagnostic Techniques Act (PNDT)  in 1994. This law was further amended into the Pre-Conception and Pre-natal Diagnostic Techniques (Regulation and Prevention of Misuse) (PCPNDT) Act in 2004 to deter and punish prenatal sex screening and sex selective abortion. The impact of the law and its enforcement is unclear. However, research shows that there was about a 0.7%-1% increase in female births after the PNDT Act was passed in 1994. Unfortunately, this data was not significant. [ 9 ]   United Nations Population Fund  and India's National Human Rights Commission, in 2009, asked the Government of India to assess the impact of the law. The Public Health Foundation of India, an activist NGO in its 2010 report, claimed a lack of awareness about the Act in parts of India, inactive role of the Appropriate Authorities, ambiguity among some clinics that offer prenatal care services, and the role of a few medical practitioners in disregarding the law. [ 90 ]  At the start of passing this act, women were still able to travel across borders to continue having sex-selective abortions. This was until the national PNDT was passed in 1996. [ 9 ]


The  Ministry of Health and Family Welfare  of India has targeted education and media advertisements to reach clinics and medical professionals to increase awareness. The Indian Medical Association has undertaken efforts to prevent prenatal sex selection by giving its members  Beti Bachao  (save the daughter) badges during its meetings and conferences. [ 90 ]


In November 2007, MacPherson estimated that 100,000 abortions every year continue to be performed in India solely because the fetus is female. [ 99 ]


For Pakistan, the United Nations Population Fund, in its 2012 report estimates the Pakistan birth sex ratio to be 110. In the urban regions, particularly its densely populated region of Punjab, report a sex ratio above 112 (less than 900 females per 1000 males). [ 100 ]  Hudson and Den Boer estimate the resulting deficit to be about 6 million missing girls in Pakistan than what would normally be expected. [ 101 ]


In 2017, two Pakistani organisations discovered large cases of infanticide in Pakistani cities. This was led by the Edhi Foundation and Chhipa Welfare Foundation. The infanticide victims were almost all were female infants. The reason given by the local authorities were poverty and local customs, where boys are preferred to girls. However, the large discovery in Karachi shows that many of the female infants were killed because of the local clerics, who ordered that out-of-wedlock babies should be disregarded. This is due to the fact that fornication is a major sin in Islam, although it is also  haram  (forbidden) to kill an innocent soul, which babies and children fall under. [ 102 ]  In fact,  Muhammad  explicitly banned the killing of female infants, as it was a custom in  Pre-Islamic Arabia . [ 103 ]


From January 2017 to April 2018, Edhi Center foundation and Chhipa Welfare organisation have found 345 such new born babies dumped in garbage in Karachi only and 99 percent of them were girls.


"We have been dealing with such cases for years and there are a few such incidents which shook our souls as much. It left us wondering whether our society is heading back to primitive age," Anwar Kazmi, a senior manager in Edhi Foundation Karachi, told The News.


Edhi Foundation has found 355 such dead infants from the garbage dumps across the country in 2017; 99 percent of them were identified girls. And Karachi has topped in this notorious ranking with 180 cases in 2017. As many as 72 dead girls have been buried in the first four months of this year by Edhi Foundation alone in the metropolitan city. The given data is just tip of the iceberg as Edhi foundation maintains the data of those cities where it provides services. [ 102 ]


Sex-selective abortion gained popularity in the mid-1980s to early 1990s in  South Korea , where selective female abortions were commonplace as male children were preferred. Historically, much of Korea's values and traditions were based on Confucianism that dictated the patriarchal system, [ 104 ]  motivating the heavy preference for sons. Additionally, even though the abortion ban existed, the combination of son preference and availability of sex-selective technology led to an increasing number of sex-selective abortions and boys born. [ 105 ]  As a result, South Korea experienced drastically high sex ratios around mid-1980s to early 1990s. [ 104 ]  However, in recent years, with the changes in family policies and modernization, attitudes towards son preference have changed, normalizing the sex ratio and lowering the number of sex-selective abortions. [ 104 ]  With that being said, there has been no explicit data on the number of induced sex selective abortions reportedly performed due to the abortion ban and controversy surrounding the topic. Therefore, scholars have been continuously analyzing and generating connections among sex-selection, abortion policies, gender discrimination, and other cultural factors.


Other countries with large populations but high sex ratios include  Vietnam . The United Nations Population Fund, in its 2012 report, [ 106 ]  claims the birth sex ratio of Vietnam at 111 with its densely populated  Red River Delta  region at 116.


Taiwan  has reported a sex ratio at birth between 1.07 and 1.11 every year, across 4 million births, over the 20-year period from 1991 to 2011, with the highest birth sex ratios in the 2000s. [ 107 ]  Sex-selective abortion is reported to be common in  South Korea  too, but its incidence has declined in recent years. [ 108 ] [ 39 ] [ 109 ]  As of 2015, South Korea's sex ratio at birth was 1.07 male/female. [ 38 ]  In 2015,  Hong Kong  had a sex ratio at birth of 1.12 male/female. [ 38 ]  A 2001 study on births in the late 1990s concluded that "sex selection or sex-selective abortion might be practiced among Hong Kong Chinese women". [ 110 ]


Recently, a rise in the sex ratio at birth has been noted in some parts of  Nepal , most notably in the  Kathmandu Valley , but also in districts such as  Kaski . [ 111 ] [ 112 ]  High sex ratios at birth are most notable amongst richer, more educated sections of the population in urban areas. [ 111 ]


Abnormal sex ratios at birth, possibly explained by growing incidence of sex-selective abortion, have also been noted in some other countries outside South and East Asia. According to CIA, the most imbalanced birth sex ratios in Europe (2017) are in Liechtenstein, Armenia, Albania, Azerbaijan, San Marino,  Kosovo and Macedonia; with Liechtenstein having the most imbalanced sex ratio in the world. [ 38 ]


The  Caucasus  has been named a "male-dominated region", and as families have become smaller in recent years, the pressures to have sons has increased. [ 113 ]  Before the  dissolution of the Soviet Union  in the early 1990s, the birth sex ratio in Caucasus countries such as  Azerbaijan ,  Armenia  and  Georgia  was in the 105 to 108 range. After the collapse, the birth sex ratios sharply climbed and have remained high for the last 20 years. [ 23 ]  Armenia, Georgia, and Azerbaijan have seen strongly imbalanced birth sex ratios in the first decade of the 21st century. [ 52 ]  In Georgia, the birth sex ratio for the years 2005–2009 was cited by  The Economist  to be about 120, a trend  The Economist  claims suggests that the practice of sex-selective abortion in the Caucasus has been similar to those in East Asia and South Asia in recent decades. [ 52 ]


According to an article in  The Economist   the sex ratio in Armenia is seen to be a function of birth order. The article claimed that among first born children, there are 138 boys for every 100 girls. [ 52 ]  Overall, the birth sex ratio in Armenia exceeded 115 in some years, far higher than India's which was cited at 108. [ 52 ] [ 114 ] [ 115 ]  While these high birth sex ratios suggest sex-selective abortion, there is no direct evidence of observed large-scale sex-selective abortions in Caucasus. [ 23 ]


According to latest CIA data, the 2017 sex ratio in the region is 112 for Armenia, 109 for Azerbaijan, and 107 for Georgia. [ 38 ]


An imbalanced birth sex ratio has been present in the 21st century in the  Western Balkans , in countries such as  Albania ,  Macedonia ,  Kosovo  and  Montenegro . Scholars claim this suggests that sex-selective abortions are common in southeast Europe. [ 3 ] [ 116 ] [ 117 ]  As of 2017, according to CIA estimates, Albania's birth sex ratio is 109. [ 38 ]  According to Eurostat and birth record data over 2008–11, the birth sex ratios of Albania and Montenegro for that period were 112 and 110 respectively. [ 51 ]  In recent years, Montenegrin health authorities have expressed concern with regard to the significant imbalance between the number of male and female births. [ 118 ]  However the data from CIA in 2017 cites the birth ratio for Montenegro within the normal range, at 106. [ 38 ]  In recent years, the birth registration data for Macedonia and Kosovo indicate unbalanced birth sex ratios, including a birth rate in 2010 of 112 for Kosovo [ 51 ] : 23    As 2017, CIA cited both Macedonia and Kosovo at 108. [ 38 ]


As in other countries, sex-selective abortion is difficult to track in the United States because of lack of data.


While the vast majority of parents in the United States do not practice sex-selective abortion, there is certainly a trend toward male preference. According to a 2011  Gallup poll , if they were only allowed to have one child, 40% of respondents said they would prefer a boy, while only 28% preferred a girl. [ 119 ]  When told about prenatal sex selection techniques such as sperm sorting and in-vitro-fertilization embryo selection, 40% of Americans surveyed thought that picking embryos by sex was an acceptable manifestation of reproductive rights. [ 120 ]  These selection techniques are available at about half of American fertility clinics, as of 2006. [ 121 ]  However, other studies show a larger preference for females. According to the Parliamentary Office of Science and Technology, 80% of American couples who wanted to get gender selection wanted girls over boys. [ 122 ]


However, it is notable that minority groups that immigrate into the United States bring their cultural views and mindsets into the country with them. A study carried out at a Massachusetts infertility clinic shows that the majority of couples using these techniques, such as  preimplantation genetic diagnosis  came from a Chinese or Asian background. This is thought to branch from the social importance of giving birth to male children in China and other Asian countries. [ 123 ]


A study of the 2000 United States Census suggests possible male bias in families of Chinese, Korean and Indian immigrants, which was getting increasingly stronger in families where the first one or two children were female. In those families where the first two children were girls, the birth-sex ratio of the third child was 1.51:1. [ 124 ]


Because of this movement toward sex preference and selection, many bans on sex-selective abortion have been proposed at the state and federal level. In 2010 and 2011, sex-selective abortions were banned in  Oklahoma  and  Arizona , respectively. Legislators in  Georgia ,  West Virginia ,  Michigan ,  Minnesota ,  New Jersey , and  New York  have also tried to pass acts banning the procedure. [ 120 ]


A 2013 study [ 115 ]  by  John Bongaarts  based on surveys in 61 major countries calculates the sex ratios that would result if parents had the number of sons and daughters they want. In 35 countries, claims Bongaarts, the desired birth sex ratio in respective countries would be more than 110 boys for every 100 girls if parents in these countries had a child matching their preferred gender (higher than India's, which The Economist claims is 108). [ 52 ]


Estimates of implied missing girls, considering the "normal" birth sex ratio to be the 103–107 range, vary considerably between researchers and underlying assumptions for expected post-birth mortality rates for men and women. For example, a 2005 study estimated that over 90 million females were "missing" from the expected population in  Afghanistan ,  Bangladesh ,  China ,  India ,  Pakistan ,  South Korea  and  Taiwan  alone, and suggested that sex-selective abortion plays a role in this deficit. [ 2 ] [ 101 ]  For early 1990s, Sen estimated 107 million missing women, Coale estimated 60 million as missing, while Klasen estimated 89 million missing women in China, India, Pakistan, Bangladesh, Nepal,  West Asia  and  Egypt . [ 18 ]  Guilmoto, [ 126 ]  in his 2010 report, uses recent data (except for Pakistan), and estimates a much lower number of missing girls, but notes that the higher sex ratios in numerous countries have created a gender gap – shortage of girls – in the 0–19 age group.


Although there is significant evidence of the prevalence of sex-selective abortions in many nations (especially India and China), there is also evidence to suggest that some of the variation in global sex ratios is due to disparate access to resources. As MacPherson (2007) notes, there can be significant differences in gender violence and access to food, healthcare, immunizations between male and female children. This leads to high infant and childhood mortality among girls, which causes changes in sex ratio. [ 99 ]


Disparate, gendered access to resources appears to be strongly linked to socioeconomic status. Specifically, poorer families are sometimes forced to ration food, with daughters typically receiving less priority than sons. [ 18 ]  However, Klasen's 2001 study revealed that this practice is less common in the poorest families, but rises dramatically in the slightly less poor families. [ 18 ]  Klasen and Wink's 2003 study suggests that this is "related to greater female economic independence and fewer cultural strictures among the poorest sections of the population". In other words, the poorest families are typically less bound by cultural expectations and norms, and women tend to have more freedom to become family breadwinners out of necessity. [ 18 ]


Increased sex ratios can be caused by disparities in aspects of life other than vital resources. According to Sen (1990), differences in wages and job advancement also have a dramatic effect on sex ratios. This is why high sex ratios are sometimes seen in nations with little sex-selective abortion. [ 19 ]  Additionally, high female education rates are correlated with lower sex ratios (World Bank 2011). [ 127 ]


Lopez and Ruzikah (1983) found that, when given the same resources, women tend to outlive men at all stages of life after infancy. However, globally, resources are not always allocated equitably. Thus, some scholars argue that disparities in access to resources such as healthcare, education, and nutrition play at least a small role in the high sex ratios seen in some parts of the world. [ 18 ]  For example, Alderman and Gerter (1997) found that unequal access to healthcare is a primary cause of female death in developing nations, especially in Southeast Asia. Moreover, in India, lack of equal access to healthcare has led to increased disease and higher rates of female mortality in every age group until the late thirties (Sen 1990). This is particularly noteworthy because, in regions of the world where women receive equal resources, women tend to outlive men (Sen 1990). Women outlive men in all but 2 countries. [ 128 ]


Economic disadvantage alone may not always lead to increased sex ratio, claimed Sen in 1990. For example, in sub-Saharan Africa, one of the most economically disadvantaged regions of the world, there is an excess of women. So, if economic disadvantage is uncorrelated with sex ratio in Africa, some other factor(s) may be at play. [ 19 ]  More detailed analysis of African demographics, in 2002, suggests that Africa too has wide variation in birth sex ratios (from 1.01 in Bantu populations of East Africa to 1.08 in Nigeria and Ethiopia). [ 36 ]  Thus economic disadvantage remains a possible unresolved hypothesis for Africa as well.


According to the 2012 report of the United Nations Fund for Population Activities on sex imbalances at birth, there are three preconditions for sex-selective abortion. [ 129 ]  First, the practice should be feasible with the availability of abortion methods and prenatal sex-screening technologies (e.g.,  obstetric ultrasonography ,  cell-free fetal DNA ,  amniocentesis ). [ 129 ] [ 130 ]  Second, changing the sex composition of children should be advantageous to the parents and the family. A variety of socioeconomic factors can account for this sex preference such as inherence rules, patronymic transmission, dowry systems, social preference of family composition. [ 129 ] [ 130 ]  Third, sex-selective abortion should be necessary because of low or decreasing fertility. Given the existence of the social benefits associated with sons, the need for having sons while maintaining a limited number of children is intensified by low fertility. [ 129 ] [ 60 ]  Low fertility can be a result of social norms of family size, rising marginal costs of an additional child, or birth control policies.


Some demographers question whether sex-selective abortion or infanticide claims are accurate, because underreporting of female births may also explain high sex ratios. [ 131 ] [ 132 ]  Natural reasons may also explain some of the abnormal sex ratios. [ 8 ] [ 25 ]  In contrast to these possible causes of abnormal sex ratio, Klasen and Wink suggest India and China's high sex ratios are primarily the result of sex-selective abortion. [ 18 ]


The reason for intensifying sex-selection abortion in China and India can be seen through history and cultural background. Generally, before the  information era , male babies were preferred because they provided manual labor and continuation of the family  lineage . Labor is still important in developing nations as China and India, but when it comes to family lineage, it is of great importance.


The selective abortion of female fetuses is most common in areas where cultural norms value male children over female children for a variety of social and economic reasons. [ 1 ]  A son is often preferred as an "asset" since he can earn and support the family; a daughter is a "liability" since she will be married off to another family, and so will not contribute financially to her parents. Sex selective female abortion is a continuation, in a different form, of a practice of  female infanticide  or withholding of postnatal health care for girls in certain households. [ 134 ]  Furthermore, in some cultures sons are expected to take care of their parents in their old age. [ 135 ]  These factors are complicated by the effect of diseases on child sex ratio, where communicable and noncommunicable diseases affect males and females differently. [ 134 ]  In parts of India and Pakistan, there are social norms such as  purdah , which stipulate that female seclusion and confinement to the home is necessary. Such practices are prevalent among some Muslim and Hindu communities in South Asia. When females interact with men, or are believed to do so, the " family honor " is tarnished.


Historically, in many South Asian populations, women were allocated a very low status, evidenced through practices such as  sati , an ancient funeral custom where a  widow  immolated herself on her husband's  pyre  or committed  suicide  in another fashion shortly after her husband's death. [ 136 ] [ 137 ] [ 138 ]  Such societies, in placing almost no value on females, encouraged parents to commit  infanticide  of girls or to abandon them. The modern practice of sex-selective abortion is therefore a continuation of other historical practices. During the 19th century, in the Northwest  British India , one-fourth of the population preserved only half the daughters, while other 3/4th of the population had balanced sex ratio. There were 118 males per 100 females. This is comparable to the contemporary sex ratio in the area, now divided between India and Pakistan. [ 139 ]


Chinese culture  is deeply patriarchal. Pre-modern Chinese society was predominantly patriarchal and patrilineal from at least the 11th century BC onwards. [ 140 ]  There has long been a son preference in China, leading to high rates of female infanticide, as well as a strong tradition of restricting the  freedom of movement  of women, particularly upper-class women, manifested through the practice of  foot binding . Although the legal and social standing of women have greatly improved in the 20th century, son preference remains still strong, and the situation was aggravated by the  one child policy .


Interpretations of  Confucianism  have been argued to contribute to the low status of women. The gender roles prescribed in the  Three Obediences and Four Virtues  became a cornerstone of the family, and thus, societal stability. Starting from the Han period, Confucians began to teach that a virtuous woman was supposed to follow the males in her family: the father before her marriage, the husband after she marries, and her sons in widowhood. In the later dynasties, more emphasis was placed on the virtue of chastity. The Song dynasty Confucian  Cheng Yi  stated that: "To starve to death is a small matter, but to lose one's chastity is a great matter." [ 141 ]  The "cult of chastity" accordingly, condemned many widows to poverty and loneliness by placing a  social stigma  on remarriage. [ 142 ]


In modern East Asia, a large part of the pattern of preferences leading to this practice can be condensed simply as a desire to have a male heir. Monica Das Gupta (2005) observes, from 1989 birth data for China, there was no evidence of selective abortion of female fetuses among firstborn children. However, there was a strong preference for a boy if the first born was a girl. [ 134 ]


Dowry  is the property that parents of a female transfer at her marriage. Dowry is an ancient practice, that has been common in many cultures around the world, and which is today prevalent especially in South Asia. The custom of dowry is most common in cultures that are strongly  patrilineal  and that expect women to reside with or near their husband's family ( patrilocality ). [ 143 ]