newborns: no longer going unnoticed 85 were fuelled by improvements in health care provision, and most studies argue that they resulted from a number of factors including rising standards of living and nutri tion, reduced fertility, safer water, better sanitation, and improved housing(26, 27) During this time, progress in reducing neonatal mortality was limited and was confined to the late neonatal period. Progress did not accelerate until around the time of the Second World War (28), which coincided with greater provision and use of maternal health care, improved quality of professional midwifery and obstetric services, and access to antibiotics. This suggests that, while some limited progress can be made in the late neonatal period as a result of general improvements in standards of living, progress will not accelerate and spread to the early neonatal period until appropriate maternal and neonatal health care is available and widely used IO LONGER FALLING BETWEEN THE CRACKS It is often argued that a radical reduction of the number of newborn deaths is possible nly where very high expenditure on health allows for large investments in sophist- cated technology. But in actual fact, nurses and doctors can easily acquire the neces ary skills without needing to become specialists. Countries such as Colombia and Sri Lanka, with fewer than 15 neonatal deaths per 1000 live births, have demonstrated that expensive technology is not a prerequisite for success. So have Nicaragua and Viet Nam, which lowered their neonatal mortality rates to 17 and 15 per 1000 births respectively, while their spending on health in the 1990s was only US$ 45 and USS 20 per capita, respectively. In northern European countries, well-coordinated antenatal intrapartum and postnatal care for mothers and newborns coincided with reduced rates of mortality before the introduction of neonatal intensive care in the early 1980s (8). Intensive care facilities, specialists and expensive equipment are useful to re duce neonatal mortality even further only after very low levels have already been achieved. Rather than deploying high-tech instrumentation, the challenge is to find a Box 5.2 Sex selection The low value given to women and girls in some juvenile(0-6 years) sex ratio declined from daughters-in-law and mothers, sex determina for boy children. Over the decades, this has with some of the steepest declines occurring gain control over at least one aspect of their translated into many practices that heavily dis- among the better educated and in economi- lives. criminate against girls, such as neglect in feed- cally better-off districts that also have greater This is a conundrum which cannot be ing, education and health care. The practice of access to commercial health services National resolved by focusing only on medical technol- female infanticide has also been documented records on sex ratio at birth in China and South ogy. The most severely affected countries such in some places Korea have shown similar rapid changes that as China, India and South Korea have all banned apidly declining fertility and the trend are unlikely to be sustainable in the long term. prenatal sex determination through the use of limit families to one or two children has The demographic impact of these adverse sex ultrasound or pre-conception techniques; other increased the desire of couples to have a boy. ratios is beginning to be felt in the form of a measures taken include registration and regu The emergence and increased availability of dearth of young women in some communities, lation of genetic laboratories and ultrasound ultrasound equipment, which can detect the thereby making women in general more vulner- machines and self-regulation by the medical sex of a fetus early in pregnancy, has opened able to violence, including sexual coercion and profession. Such policies have so far been p the opportunity for the commercial use of sale of brides. rgely ineffective because demand continues to medical technology to pre-select and terminate Many women s rights organizations and oth- be high. Various nongovemmental organizations pregnancies of female fetuses, thus reinforcing ers, in India and elsewhere, have seen prenatal and civil society organizations are currently the devaluation of girls and women. x selection as another form of discrimination involved in large-scale awareness and sensi Over the last decade, the ratio of girls to against women, and have been active in moves tization campaigns and in organizing a broader yys in the 0-6 year age group has become to have such selection banned. On the other social debate on the devaluation of females and creasingly skewed in a number of countries. hand, in societies where giving birth to sons the consequences of sex preference. For instance, India' s census revealed that the defines women' s status and rights as wivesnewborns: no longer going unnoticed 85 were fuelled by improvements in health care provision, and most studies argue that they resulted from a number of factors including rising standards of living and nutri￾tion, reduced fertility, safer water, better sanitation, and improved housing (26, 27). During this time, progress in reducing neonatal mortality was limited and was confined to the late neonatal period. Progress did not accelerate until around the time of the Second World War (28), which coincided with greater provision and use of maternal health care, improved quality of professional midwifery and obstetric services, and access to antibiotics. This suggests that, while some limited progress can be made in the late neonatal period as a result of general improvements in standards of living, progress will not accelerate and spread to the early neonatal period until appropriate maternal and neonatal health care is available and widely used. NO LONGER FALLING BETWEEN THE CRACKS It is often argued that a radical reduction of the number of newborn deaths is possible only where very high expenditure on health allows for large investments in sophisti￾cated technology. But in actual fact, nurses and doctors can easily acquire the neces￾sary skills without needing to become specialists. Countries such as Colombia and Sri Lanka, with fewer than 15 neonatal deaths per 1000 live births, have demonstrated that expensive technology is not a prerequisite for success. So have Nicaragua and Viet Nam, which lowered their neonatal mortality rates to 17 and 15 per 1000 births, respectively, while their spending on health in the 1990s was only US$ 45 and US$ 20 per capita, respectively. In northern European countries, well-coordinated antenatal, intrapartum and postnatal care for mothers and newborns coincided with reduced rates of mortality before the introduction of neonatal intensive care in the early 1980s (8). Intensive care facilities, specialists and expensive equipment are useful to re￾duce neonatal mortality even further only after very low levels have already been achieved. Rather than deploying high-tech instrumentation, the challenge is to find a juvenile (0–6 years) sex ratio declined from 945 girls per 1000 boys in 1991 to 927 in 2001, with some of the steepest declines occurring among the better educated and in economi￾cally better-off districts that also have greater access to commercial health services. National records on sex ratio at birth in China and South Korea have shown similar rapid changes that are unlikely to be sustainable in the long term. The demographic impact of these adverse sex ratios is beginning to be felt in the form of a dearth of young women in some communities, thereby making women in general more vulner￾able to violence, including sexual coercion and sale of brides. Many women’s rights organizations and oth￾ers, in India and elsewhere, have seen prenatal sex selection as another form of discrimination against women, and have been active in moves to have such selection banned. On the other hand, in societies where giving birth to sons defines women’s status and rights as wives, The low value given to women and girls in some countries is reflected in a marked preference for boy children. Over the decades, this has translated into many practices that heavily dis￾criminate against girls, such as neglect in feed￾ing, education and health care. The practice of female infanticide has also been documented in some places. Rapidly declining fertility and the trend to limit families to one or two children has increased the desire of couples to have a boy. The emergence and increased availability of ultrasound equipment, which can detect the sex of a fetus early in pregnancy, has opened up the opportunity for the commercial use of medical technology to pre-select and terminate pregnancies of female fetuses, thus reinforcing the devaluation of girls and women. Over the last decade, the ratio of girls to boys in the 0–6 year age group has become increasingly skewed in a number of countries. For instance, India’s census revealed that the daughters-in-law and mothers, sex determina￾tion and sex selective abortion allow women to gain control over at least one aspect of their lives. This is a conundrum which cannot be resolved by focusing only on medical technol￾ogy. The most severely affected countries such as China, India and South Korea have all banned prenatal sex determination through the use of ultrasound or pre-conception techniques; other measures taken include registration and regu￾lation of genetic laboratories and ultrasound machines and self-regulation by the medical profession. Such policies have so far been largely ineffective because demand continues to be high. Various nongovernmental organizations and civil society organizations are currently involved in large-scale awareness and sensi￾tization campaigns and in organizing a broader social debate on the devaluation of females and the consequences of sex preference. Box 5.2 Sex selection