Perception of Prenatal Sex Selection among Women Attending ...

Perception of Prenatal Sex Selection among Women Attending AntenatalClinic in a South Western Nigerian Town

Imaralu John 0, Ani Franklin I, Olaleye Atinuke 0, Sotunsa John 0, Adelowo Olumuyiwa °Department of Obstetrics and Gynaecology, Babcock University Teaching Hospital, Ilishan-Rerno, Nigeria.

AbstractObjective: To determine the perception of child sexselection and the factors affecting acceptance ofassisted reproductive techniques for child sex selectionamong pregnant women in Ogun state, SouthwesternNigeria.

In-vitro fertilization with embryo transfer (71.3%) isthe method of assisted conception most known to therespondents while selective embryo transfer is thecommonest method of prenatal sex selection they areaware of (42.6%). Educational level (p<0.00 1),ethnicity (p<O.05) and religion (p<0.001), determinedthe acceptance of prenatal sex selection. Most (77.8%)of the respondents who welcomed the idea, wouldundergo procedures to have a male child; a choicewhich however did not significantly influence theiropinion on legal regulation of these procedures.

Methods: A cross sectional survey conducted among400 antenatal clinic attendees in the three largesthospitals in Sagamu and its environs in Ogun state.

Results: Participants were mostly Yorubas (83.1%),Christians (71.5%) and had tertiary education (52.8%).The male child was preferred among respondents whoindicated their choice (84.8%). Relative subfertilitybefore index conception influenced the preference for amale child (p<0.001); it however, did not have anysignificant influence on awareness of methods ofprenatal sex selection (p=0.965, CI=0.960-0.969).Presence of existing male children had a significantlynegative effect on preferred child sex (p=0.377,CI=0.365-0.390).

Conclusion Pregnant women in Sagamu are mostlyaware of assisted reproductive techniques for prenatalsex selection and would consider them for difficulty inbearing male offspring. This choice however did notsignificantly affect their attitudes towards legalrestrictions of sex selective procedures.

Corresponding Author Dr Imaralu John Osaigbovoh, Department of Obstetrics and Gynaecology, BabcockUniversity Teaching Hospital Ilishan-Remo. .'E-mail: [email protected], Phone: 2348067857419

Introduction especially in South-east Asia, child gender bias has ledThe use of medical techniques to choose to practices resulting in detectable distortion of sex-

offspring gender has advanced to a point where ratio at birth.' .outcomes can be considered a result of choice rather Similarly, reports from the 2001 census inthan chance. Improvements in the understanding of the India, revealed a substantial decline in the number ofgenetic basis for diseases and advances in pre- girls per 1000 boys under 6 years of age.' A findingimplantation genetic diagnosis have been the major which made the Indian government enact legislation todriving forces behind increasing demand and indeed regulate assisted reproductive techniques.success in prenatal child gender selection. Techniques in sex selection have gone from

These procedures have brought relief to remedies involving alteration in timing and nature ofcouples seeking to prevent sex-linked or sex-related sexual intercourse to advances in manipulation ofgenetic disorders such as muscular dystrophy, gametes. Intercourse at full moon, under the influencehemophilia, Fragile X-syndrome and autism. Sex of alcohol or consumption of certain kinds offood itemsselection for achieving offspring gender balance in in addition to pinching or other stimulation of the testishomes and for other social, cultural and economic before coitus has been reported.'reasons however continues to raise serious ethical and Sex selective infanticide was practiced inmoral questions+Dffspriag gender bias and prenatal a n c ie n t Greece, Rome and in the Arabsex selective remedies have existed through history; world/Recomrnendations were widely made for coitusrecent advances in assisted reproductive technology just before ovulation and for douching before sexualhowever have brought this issue up again in many intercourse, in order to increase chances of conceptioncycles for debate. of a male child.

Child gender preference and consequent sex This was based on the thinking that Y_selective procedures have wide geographi~al. ',an? chromosome bearing spermatozoa are more motile and

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Table 1: Perception and attitude to offspring gender preferenceand prenatal sex selection techniques.

Variable Frcoucncv PerccntazeChild gender preferred

22.2Male - 89Female 16 4.0.No preference 295 73.R

n=400Knowledge of Assisted conception methodsIUI 35 20.5IVF 122 71.3(CS( .., I.R.)

PGD 11 6.4\1=171

Awareness of prenatal medical selection of offspringsexYes 208 53.1No 184 49.6

\1=392Knowledge of methods of medical sex selection

Selective egg fertilization 65 36.9Selective embryo transfer 75 42.6Sex selective abortion 36 20.5

n =176Acceptance of prenatal sex selectionYes lR5 47.7

0 63 16.2Indifferent 140 36.1.

n =3RRPreferred child gender to medically selectMale loR 77.RFemale 44 20.4lnd iffcrenr 4 1.8

n =216

Relative subfertility before index conception,significantly influenced preference for a male child(p<0.001), however, ethnicity (p=0.344, CI=0.332-0.356) and parity (p=0.288, CI=0.277-0.300), did nothave similar influence. Presence of existing malechi Idren had a significantly negative effect on preferredchild sex (p=0.377, CI=0.365-0.390) (Table 2).

Relative subfertility before conception(p=0.965, CI=O.960-0.969) did not have any significantinfluence on awareness of methods of prenatal sexselection. Educational level (p<O.OOI), ethnicity(p<0.05) and religion (p<O.OOI), determined theacceptance of prenatal sex selection (Table 3).

© 2015 Babcock University Medical Journal 31

Table 1: Perception and attitude to offspring gender preferenceand prenatal sex selection techniques.

Variable Frcuuencv PcrccntazeChild gender preferred

22.2Male - 89Female 16 4.0.No preference 295 73.R

n=400Knowledge of Assisted conception methodsIUI 35 20.5IVF 122 71.3ICS] 3 l.RPGD 11 6.4

11=171Awareness of prenatal medical selection of offspringsexYes 208 53.1

0 184 49.6n =392

Knowledge of methods of medical sex selection

Selective egg fertilization 65 36.9Selective embryo transfer 75 42.6Sex selective abortion 36 20.5

n =176Acceptance of prenatal sex selectionYes 185 47.7

0 63 16.2Indifferent 140 36.1,

n =3RRPreferred ehild gender to medically selectMale 16R 77.RFemale 44 20.4indifferent 4 1.8

n =216

Relative subfertility before index conception,significantly influenced preference for a male child(p<O.OOl), however, ethnicity (p=0.344, CI=0.332-0.356) and parity (p=0.288, CI=0.277-0.300), did notlrave similar influence. Presence of existing malechildren had a signi ficantly negative effect on preferredehild sex (p=0.377, CI=0.365-0.390) (Table 2).

Relative subfertility before conception(p=0.965, CI=0.960-0.969) did not have any significantinfluence on awareness of methods of prenatal sexselection. Educational level (p<0.00 1), ethnicity(p<0.05) and religion (p<0.001), determined theacceptance of prenatal ex selection (Table 3).

© 2015 Babcock University Medical Journal 31

r-'T::Ible..2J)p.t erminants af..chili:lg@deLJ2[efemnr.p.

Preferred child sexVariable Malc Female No preference p-value

n(%) n(%) nT%)Years before conception: N = 395< 1 year ( n - 272) 46(16.9) 9 (3.3) 217(79.8)1-5 years ( n = 105) 36 (34.3) 7 (6.7) 62 (69.0)>5 year ( n -r- 18) 7 (38.9) 0(0) 11 (61.1) < 0.001

Parity: N= 394o (n= 122) 20 (16.4) 3 (2.5) 99 (81.1)I (n= 101) 21 (20.8) 7 (6.9) 73 (72.3)2(n= ]g) 22 (21D) 2 (2.6) 54(69.2)3(11=(0) 18 (30.0) 2 (3.3) 40 (06.7)4(11=27) 6 (22.2) 2 (7.4) 19(70.4) o.zss5(n- 6) 2 (33.3) 0(0) 4 (66.7)

Existing malt: children:N = 391o (n-227) 58 (25.6) 10(4.4) 159 (70.0)1 (n=119) 21 (17.6) 3 (2.5) 95 (79.9)2 (n-32) 8 (25.0) 2 (6.3) :n (68.7) 0.3773 (n= 13) 2 (15.4) 1 (7.7) 10 (76.9)

Ethnicity : N- 397Yoruba (n= 330) 70 (21.2) 14 (4.2) 246 (74.6)Igbo (n- 56) 18 (32.1) 2 (3.6) 36 (64.3) 0.344Hausa In= 11) 1 (9.1) 0 (0) 10 (90.9)

Religion N=400Christianity (n=286) 75 (26.2) 3 ( 1.0) 208 (72.7)Islam (11=99) 13(13.1) 5 (5.1) gl (gU)Traditional (11=8) I .(12.5) 4 (50.0) 3 (37.5)Other (n=7) 0 (0) 4 (57.1 ) 3 (42.9) <0.001~ -'--

Table 3: Determinants of acceptance of prenatal child sex selection

Factor

~c1igion: =388::-hristiallity (n = ~75)slam (n = 98)Iraditional (11= 8)lthers (11 = 7)::'thnicity: =385I'oruba (n = 3~1)gbo (n=56)lausa (n=8)~dllc~tiollal Lex et: 1=3~6~onc (n =13))rimary (n= 42)Secondary (n = 130)Fcrriarv (n = ~O1)

- - -AcceptanceYes No Indifferent p- value (Fisher's exact)n (%) n (%) n (%)

141 (51.2) 51 (18.6) 83 (30.~)4~(42.8) 4 (4.1 ) 5~ (53.1)

I 2(~5.0) I ( 12.5) 5 (62.5)0(0) 7 (100) 0 (0) <0.001

I 154(48.0) 45 (14.0) 122 (38.0)123(41.1) 16 (28.6) 17 (30A)

5(6~.5) ~ (:25.0) I ( 12.5) <0.05

6 (46.2) ~ (15 .."\) 5 (38.5)II (26.2) 18 (42.9) 13 (30.9)65 (50.0) 12 (9.2) 53 (40.8)102 (50.7) 31 (15.4) 68 (33.9) <0.001

The male child was preferred amongrespondents who indicated their choice(84.8%).Child gender preference and choice ofgender to medically select had no statistically

significant influence on th ir attitude towardslegal regulation of sex selective procedures (Table4).

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Table 4: Attitude towards legal regulation of sex selection

Liberalize regulations for child sex selectiveprotedures.

Yes No Indifferent totalFactor p-value

n (%) n (%) n (%) n (%)

Child gender preference

Male 24 (28.0) , 7 (20.2) 43 (51.2) 84 (100)

Female 3 (I g.g) 5 (31.3) 8 (50.0) 16(100)

No preference 72 (25.4) 53 (18.7) 158 (55.9) 283 (100) 0.719

Total 199 75 109 383

Child sex to medically select ¥ -\ .. - .. ~ "

Male (j I(38.1) 29 (18.1) 70 (43.8) 100 (100) .. -Female 10(33.3) 9 (18.8) 23 (47.9) 48 (100) 0.855

Total 77 36 93 208

r,

DiscussionSex is a biologically determined phenomenon,

once born; an individual's sex cannot be changed."Gender however, is socially determined and subject tochanges based on societal needs and individualpreferences, it is not determined by biological orphysiological capability. Societies have traditionallyassigned roles, expectations and responsibilities thatcharacterize particular gender.":" Inability to adjustroles or understand this difference has been thought tobe responsible for many societies developing. ormanifesting a particular gender preference as actualoffspring sex preference.'?"

Preference for the male child appears to be thenorm observed among respondents in this study inSagamu, it is also the general trend in studies conductedin other parts of Nigeria and Asia.2J

·27A survey

conducted among Nigerian men also shows a similartrend.25.:!8.:!9

This has important implications: for instancein most of East em Nigeria where it is accepted that sonsare more likely to provide for the family in old age,bring in wives who add to the workforce and overallincome and represent families at socio-cultural-religious functions in a family system which ispredominantly patrilineal and patriarchal. Here sonsshould be 'successors and continue the family line';religious rites such as funerals are handled by malesregardless of their position in the family.":" All thesehave resulted in male dominance of inheritance rights,ge~der ineq~ality, bias in quality and level of the girl-child education, reduced female earnings, less femaleautonomy and violence against women.20-2>

Contrary to earlier observations in studiesfrom othe~ parts of the country,":" ethnicity and thenumber ot eXIsting male children did not bave anystatistical~y significant influence on preference for themale ?l~lld gender among respondents. Relativesubfertility before index conception was a major

determinant of preference of the male child gender, asrespondents with longer intervals before conceptionincreasingly preferred to have a male child. In addition,Christians and Muslims preferred the male child, whencompared with other religious groups.

In-vitro fertilisation is the method of assistedconception, known by most of the respondents(71.3%); the semi-urban nature of the study locationand proximity to Lagos - a megacity and formernational capital territory (where these techniques arereadily available), may be responsible for thisawareness. In addition, most of the respondents(52.8%) had tertiary education and are of low parity(56.6% were para 0 orpara 1).

Child gender preference is a major contributorto sex selective abortion especially in Asia and to highparity in sub Saharan Africa, which are majordeterminants of maternal morbidity and mortality inthese settings.i" 26 ;21,28.Reports from studies in Nigeriashow that most couples would continue having morechildren until they get a male child. This has greatpotential for increasing grand multiparity rates andgrowth in the proportion of dependent population":"

Inability of a couple to produce a maleoffspring is a recognised cause of social and maritalfriction in Nigeria.28.29.3IItis thus not surprising that alarge proportion of the participants are aware ofprenatal child sex selection(53.1%). Selective embryotransfer observed in this study, as the method of prenatalsex selection most known to the respondents (45%) ishowever, a markedly different response whencompared to sex selective abortion, which is mostlyreported among Southeast Asians.2o

•21 .

Although participants with relativesubfertility preferred the male gender for their offspring(p<O.OOl), this issue did not have any statisticallysignificant effect on knowledge of prenatal sexselection (p=O.965).Re1igion has a strong influence 011

acceptance of prenatal child sex selection III Sagamu

© 2015 Babcock University Medical Journal 33

(p< 0.00 1), with Christians and Muslims being more infavour. Although most participants with preferencechose the male offspring, this choice however did notsignificantly affect their attitude towards legalregulations of sex selective procedures. Prenatal sexselection for medical conditions is readily acceptable inthe developed countries where Christianity and Islampredominate and educational level is high (comparableto this study population). However, its use for non-medical reasons in these developed countries is still

. I)debatable.

The quantitative nature ofthis study; using theLikert scale limited our ability to explore the reasonsbehind male child sex preference and preference toselect the male child sex when there is access to assistedreproductive technology .. Qualitative explorativeresearch would be required to clarify these issues.

ConclusionPregnant women in Sagamu are mostly aware

of assisted reproductive techniques for prenatal sexselection and would consider them for difficulty inbearing male offspring. This choice however did notsignificantly affect their attitudes towards legalrestrictions of sex selective procedures.

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