Emerging Issues: Ageing, Sex Ratios, Child and Infant Mortality, Reproductive Health

Why These Four Issues Are Grouped Together

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• Ageing, the declining sex ratio, child and infant mortality, and reproductive health are treated together as India’s “emerging” population issues because each is a second-order consequence of the demographic transition traced in the earlier articles of this series — they are what happens once a population’s growth rate has begun slowing, rather than problems of growth as such. A society that succeeds in lowering its birth and death rates inherits a different set of demographic anxieties: it ages, its earlier son-preference behaviours become visible in a shrinking pool of children, and the health of its remaining births and mothers becomes the central unfinished task of public health policy.

Ageing: Defining and Classifying Old Age

• Ageing has been defined variously across the sociological and demographic literature. Becker defines it in the broadest sense as “those changes occurring in an individual as a result of the passage of time.” Stieglitz frames it as a lifelong process — “ageing is a part of living; it begins with conception and terminates with death.” Tibbitts offers a more social definition: ageing is “the survival of a growing number of people who have completed the traditional adult roles of making a living and childrearing.”
• Sociologists distinguish physical ageing from social ageing — the two need not coincide. Physical ageing is conditioned by health status, while social ageing may instead track retirement from the production process; in the Indian rural context specifically, social ageing carries additional cultural weight, since the aged in a still-agrarian, past-oriented society function as living links to tradition, whereas in urbanised and industrialised settings, ageing tends to bring a shift from an authoritarian-patriarchal family role toward a more equal, less deferential one.
• Classification of old age varies by institution: the WHO treats 60-74 as “elderly,” while the UN, from 1980, recommended age 60 as the transition point into the elderly segment, sub-dividing it into “young-old” (60-75), “old-old” (75-85), and “very old” (85+). India’s own Census has adopted 60 as the threshold for classifying a person as old, which conveniently coincides with the retirement age in much of the government sector.

Why Ageing Is Emerging as a Social Problem in India

• The scale of India’s ageing population has grown steadily across every count since independence: from 20.19 million in 1951 (5.5% of the population) to 43.17 million in 1981, 55 million in 1991, 77 million by the 2001 Census (7.5%), and 103.8 million by the 2011 Census (8.6%) — a growth rate for the elderly population (2.89% during 1991-2001) that has consistently outpaced the overall population growth rate (2.02%) over the same period. Projections put this figure at roughly 177.4 million by 2025, rising further to around 193.4 million by 2031, and — most strikingly — to 230 million by 2036, or nearly 15% of the total population, meaning close to one in seven Indians will be a senior citizen within that horizon; longer-range UN-linked projections put the figure at 319 million by 2050.
• The underlying sociological cause is not simply “more old people” but a structural transformation of the family and economy:
  • Industrialisation and urbanisation have replaced family-based production units with mass production and factory employment, so economic transactions increasingly occur between individuals rather than within family units, and income differentials open up within families as members earn independently — while push factors (population pressure) and pull factors (economic opportunity, modern communication) draw younger members away from rural areas altogether.
  • The disintegration of the joint family system and the corresponding rise of the nuclear household — driven by education, urbanisation, and a desire for privacy and independence — mean elderly parents left in villages by migrating children increasingly face loneliness and a shortage of caregivers, while those living with adult children in cities find their traditional authority over the household eroded.
  • Sociologically, ageing is best understood as a transition between social roles, and the transition into the role of “old” is one of the most complex of all such role changes. In a traditional agrarian society, where children followed their parents’ occupation, the older generation’s expertise remained genuinely useful to the next; rapid technical change and formal education in a modern setting have instead rendered much of that older knowledge and experience obsolete in the eyes of younger family members, producing feelings of loss of status, uselessness, and loneliness among the aged — sharpened further where an older person remains economically dependent on children who no longer seek out their guidance.
  • The rise of dual-career households, with women’s growing workforce participation across the urban informal sector, the formal middle class, and rural areas alike, cuts both ways for elderly care: it can make grandparents’ presence emotionally valuable for childcare, but rising housing and healthcare costs simultaneously make it harder for working couples to have ageing parents live with them.

Sociological Perspectives on Ageing

• Beyond descriptive demography, several sociologists have offered explanatory frameworks for how societies treat their elderly.
• Peter Townsend’s political economy of old age situates ageing within the labour market and government policy rather than treating it as purely a biological fact — inadequate state pensions, he argues, push people who had too little income to save during their working lives into poverty once they retire, meaning old-age poverty is substantially a policy outcome, not an inevitability.
• Linda R. Gannon argues that ageing affects women more adversely than men, owing to lifestyles, expectations, and caregiving roles that leave women materially disadvantaged — paid less over a working life and burdened with greater unpaid caring responsibility — and observes that menopause has often been medicalised as a “disease” requiring hormone treatment, even though men undergo a comparable hormonal decline with age that draws no equivalent clinical concern.
• Jenny Hockey and Allison James describe elderly people as frequently “infantilised” — compared to and treated as children — and argue that both childhood and old age are social constructs linked by a shared theme of imposed dependency, even though people at both life stages are often capable of far more independence than society typically permits them.
• Lorraine Green defines ageism as the systematic stereotyping of, and discrimination against, individuals purely on the basis of their age — a concept that gives the everyday marginalisation of the elderly a name comparable to racism or sexism.
• Disengagement theory holds that individuals gradually withdraw from social life as they enter old age, a process read by its critics as at least partly imposed by society rather than freely chosen. Related to this, social exchange theory suggests that relationships persist only where both parties find them mutually beneficial — as older people have progressively less to offer in material or status terms, their relationships can become strained, adversely affecting their wellbeing.

Problems Faced by the Aged in India

• The problems the aged face in India fall into recognisable clusters rather than a single undifferentiated hardship.
• Economic problems — loss of income on retirement from the formal sector, or declining capacity to work in the informal and agricultural sectors, sometimes compounded by loss of control over family finances or property once these responsibilities are shifted to adult children.
• Psychological problems — powerlessness, a sense of inferiority, depression, and isolation, with elderly women in particular reporting an “empty nest syndrome” as their household role diminishes.
• Health problems — a higher prevalence of chronic illness, poor mental health, and physical disability, compounded by the fact that roughly eight in ten older Indians live in rural areas, where healthcare access is weakest (per the 2001 Census).
• Widowhood adds a distinct further vulnerability, given the tradition of women marrying older men, women’s greater longevity, social disapproval of widow remarriage, and patrilineal inheritance norms that frequently leave widows without independent assets or income.

State Response and International Framework

• India’s institutional response includes the National Policy for Older Persons (1999), approved to coincide with the UN’s International Year of Older Persons, and the Maintenance and Welfare of Parents and Senior Citizens Act, 2007, which gives elderly parents a legal right to seek maintenance from their children through a maintenance tribunal — building on earlier legal provisions such as Section 125(1)(d) of the Code of Criminal Procedure, 1973, and Section 20(3) of the Hindu Adoption and Maintenance Act, 1956.
• Old age homes, though not historically common in India, have grown steadily since the first was established in Bangalore in 1983; the majority remain charitable institutions for the destitute, though a growing share now operate on a “pay and stay” basis. This growth is itself contested: some argue that expanding institutional care will let children abdicate their filial responsibilities and erode traditional family-based care, while others argue that with a growing elderly population and declining family capacity to provide care, such institutions are simply a practical necessity.
• Internationally, formal recognition of ageing as a policy issue is comparatively recent: the UN first debated the question at Argentina’s initiative in 1948, Malta raised it again in 1969, and the UN convened its first World Assembly on Ageing in Vienna (1982), which produced the International Plan of Action on Ageing; the UN subsequently designated 1 October as the International Day of Older Persons (from 1990) and observed 1999 as the International Year of Older Persons. A Second World Assembly on Ageing was held in Madrid in 2002, focused on guaranteeing economic and social security for the elderly, addressing declining family support, and the burden on elderly caregivers of children orphaned by the AIDS epidemic. India’s own national policy process ran roughly parallel to this international timeline, with a policy framework drafted in 1990 and finalised in 1999.
• India’s contemporary institutional response includes the Atal Vayo Abhyuday Yojana (AVYAY), an umbrella scheme covering old-age homes, continuous care centres, and mobile Medicare units, and the National Programme for Health Care of the Elderly (NPHCE), which by the mid-2020s had extended dedicated geriatric outpatient services, ten-bedded geriatric wards, physiotherapy, and diagnostic support to over 700 health districts nationally — a substantial expansion of the “care economy” infrastructure this literature has long argued India needs.

The Declining Sex Ratio: Trends and Regional Patterns

• The sex ratio — conventionally the number of females per 1,000 males — has historically favoured females slightly in most human populations, but India’s overall sex ratio has been in long-term decline for over a century: from 972 at the start of the twentieth century, it fell to 941 by 1961, reached an all-time low of 927 in 1991, and then posted a modest recovery to 933 in 2001 and 940 by the 2011 Census.
• Far more alarming to demographers than the overall ratio is the child sex ratio (0-6 years), computed separately since 1961. Historically substantially higher than the overall sex ratio, it has since fallen sharply and, unusually, fallen below the overall ratio for the first time in the 1991-2001 decade: even as the overall ratio posted its best-ever decadal gain (927 to 933), the child sex ratio plunged from 945 to 927, an 18-point drop in the opposite direction. By the 2011 Census, the child sex ratio had fallen further still, to 914 — its lowest level since independence.
  • The state-level pattern is especially telling: the worst-affected states and union territories cluster in the north-west — Punjab has recorded the lowest child sex ratio of any major state, with Haryana, Chandigarh, Delhi, Gujarat, and Himachal Pradesh also among the poorest performers (together sometimes referred to in exam literature as the “DEMARU” cluster of states, per the 2017 UPSC question on this topic) — while states such as Sikkim and Kerala perform comparatively well, though even Kerala’s ratio is not exceptional by international standards.
• Contemporary data (NFHS-5 and SRS) shows only partial improvement: the sex ratio at birth for the five years preceding the survey stood at 929 females per 1,000 males (NFHS-5, 2019-21), and the SRS Statistical Report for 2023 recorded a child sex ratio of around 935 — a genuine if modest recovery, credited partly to schemes like Beti Bachao Beti Padhao (2015) and stricter awareness against prenatal sex selection. State-level disparities remain stark: Chhattisgarh (969) and Kerala (964) show comparatively balanced ratios, while Haryana (834) and Punjab (846) remain the weakest performers nationally — and Haryana’s sex ratio at birth actually fell to 910 in 2024, its lowest since 2016, a reminder that this recovery is neither linear nor secure.

Explaining the Decline in the Sex Ratio

• Demographers and sociologists have systematically ruled out and then narrowed down the likely causes of this decline.
  • Maternal mortality is not the explanation. It is plausible on its face that higher female mortality during childbirth could depress the sex ratio, but maternal mortality has been declining steadily with development even as the sex ratio worsened over the same period — the timing does not fit, so this factor cannot account for the trend.
  • Differential treatment of girl children is the better-supported explanation, given that the decline in the child sex ratio has been far steeper than in the overall ratio — pointing toward mechanisms specific to infancy and early childhood rather than to adult female mortality. Three specific mechanisms are typically identified: severe neglect of girl infants leading to higher death rates, sex-selective abortion following prenatal sex determination, and outright female infanticide in some regions, historically linked to religious or cultural belief.
  • The “prosperity paradox.” The regional pattern of low child sex ratios directly undercuts any explanation resting on poverty or lack of resources: the states with the worst child sex ratios — Punjab, Haryana, Delhi, Gujarat — are among India’s most prosperous, not its poorest. If dowry-related financial strain explained sex selection, wealthier households (best able to absorb such costs) should show better ratios, not worse ones. This paradox is instead read as evidence that as prosperous families choose to have fewer children overall — often just one or two — they increasingly also seek to choose the sex of those few children, a preference that widely available ultrasound technology has made technically feasible even though the law strictly prohibits its use for this purpose.

Policy and Legal Response to the Sex Ratio Decline

• The principal legal instrument is the Pre-Natal Diagnostic Techniques (Regulation and Prevention of Misuse) Act, in force since 1996 and substantially strengthened in 2003 as the PCPNDT Act, which bans the use of diagnostic technology to determine and selectively act on a foetus’s sex, backed by heavy fines and imprisonment.
• Enforcement has nonetheless been uneven: the legal framework, while robust on paper, has in recent years seen reports of laxer enforcement, which analysts partly link to the concerning reversal in states like Haryana noted above — a reminder that the long-run solution to sex-selective practices depends at least as much on how underlying social attitudes toward daughters evolve as on the strength of formal law.
• Beti Bachao Beti Padhao, launched in 2015, represents India’s most prominent contemporary policy response, combining awareness generation with targeted interventions on girls’ survival, protection, and education, and is widely credited alongside stricter PCPNDT enforcement for the partial recovery in the child sex ratio recorded through the 2010s and early 2020s.

Child and Infant Mortality

• Several related indicators are used to measure early-life mortality, each defined precisely because each captures a different stage of vulnerability:
  • Infant Mortality Rate (IMR) — deaths of children under one year of age, per 1,000 live births in a given year.
  • Child Mortality Rate / Under-Five Mortality Rate — deaths of children before their fifth birthday, per 1,000 live births.
  • Neonatal Mortality Rate (NNMR) — deaths within the first month of life, and Post-Neonatal Mortality Rate (PNNMR) — deaths from one month to eleven months, the latter substantially driven by infectious disease such as diarrhoea and acute respiratory infection.
• Neonatal deaths have historically constituted a disproportionate share of India’s overall infant mortality — over 70% of the IMR at points in the 2010s — for reasons that go beyond simple lack of medical access: the sharp rise in institutional deliveries under the National Rural Health Mission was not matched by a proportionate fall in neonatal deaths, suggesting that the quantity of institutional delivery matters far less than the quality of newborn care available once a mother reaches the facility. Widespread maternal undernutrition and anaemia compound this, producing a substantial share of underweight births that many public facilities lack the specialised newborn-care capacity to manage — a public health gap the National Rural Health Mission alone was never structurally positioned to close.
• The socio-cultural roots of high infant and child mortality are as important as the clinical ones: a broadly fatalistic cultural attitude toward childbearing, reinforced from childhood, discourages the exercise of reproductive self-determination; children are widely regarded as “gifts” whose number is not fully a matter of parental choice; high infant and child mortality itself perpetuates large family size, since couples may deliberately have more children in the expectation that not all will survive to adulthood; and the generally low social status of women limits their ability to negotiate childbearing decisions or seek alternative avenues of self-expression, all of which sustain the very fertility levels this series has traced from a sociological rather than purely medical angle.
• Contemporary data marks substantial, measurable progress: India’s IMR has fallen from 39 per 1,000 live births in 2014 to 25 in 2023, and further to an estimated 24 in 2024 (SRS). The Neonatal Mortality Rate fell from 26 (2014) to 19 (2023), and the Under-Five Mortality Rate from 45 (2014) to 29 (2023) — figures that place India within reach of, though not yet at, the SDG target of an under-five mortality rate of 25 by 2030.

Reproductive and Maternal Health

• Maternal Mortality Ratio (MMR) — deaths from any cause related to or aggravated by pregnancy or its management, per 100,000 live births — is treated as one of the single most sensitive indicators of a health system’s reach to the poor, precisely because maternal death is overwhelmingly preventable given adequate, timely care.
• Related but distinct measures include the Maternal Mortality Rate (maternal deaths per 100,000 women of reproductive age in a period, distinguishing it from MMR’s live-birth denominator) and the adult lifetime risk of maternal death (the probability that a 15-year-old girl will eventually die of a maternal cause over her lifetime) — both of which fell substantially through the 2000s and 2010s alongside MMR itself, and both of which showed persistent state-level variation, with Kerala consistently the best performer and states such as Uttar Pradesh/Uttarakhand and Assam among the weakest.
• India’s government has run a wide array of interventions under the National Rural Health Mission (2005) and its Reproductive and Child Health umbrella, including the Janani Suraksha Yojana (JSY), a demand-side cash-incentive scheme that sharply increased institutional deliveries among SC/ST and BPL women; standardised antenatal, intranatal, and postnatal care protocols; expansion of Basic and Comprehensive Emergency Obstetric Care at the Sub-Centre through District Hospital level; the ASHA (Accredited Social Health Activist) cadre, which drives demand and facilitates access to institutional care at the village level; the Mother and Child Tracking System (MCTS), an online tool for name-based tracking of pregnant women and children; and the Janani Shishu Suraksha Karyakaram (JSSK, 2011), which entitles all women delivering in public facilities to entirely free delivery, including caesarean section, along with free drugs, diagnostics, blood, and transport.
• Contemporary data shows a marked and accelerating decline in maternal mortality: India’s MMR fell to 93 per 100,000 live births by 2019-21, and further to 88 by 2021-23 — the latest SRS figure — down sharply from 130 in 2014-16 and from the 178 (2010-12) figure that older notes on this topic still commonly cite. Per the 2025 UN Maternal Mortality Estimation Inter-Agency Group report, India’s MMR has declined by 86% since 1990, against a global reduction of only 48% over the same 33-year period — a pace of improvement that stands out even in international comparison.
• On the scheme architecture itself, the earlier Indira Gandhi Matritva Sahyog Yojana (IGMSY, 2010) — a conditional cash-transfer piloted in select districts — has since been superseded and nationalised as the Pradhan Mantri Matru Vandana Yojana (PMMVY), which provides ₹5,000 for a first child (paid in tranches tied to antenatal check-up and immunisation milestones) and ₹6,000 where a second pregnancy results in a girl child, with eligibility linked to schemes such as Ayushman Bharat/PMJAY, BPL status, or income thresholds — reflecting the same broader shift, traced throughout this series, from narrow demographic targeting toward welfare- and rights-based framing of reproductive health policy.
• The available evidence on unmet need in reproductive health remains sobering even against this backdrop of measurable progress: a substantial share of conceptions in India are unplanned, a meaningful share of pregnancies end in induced abortion (as against spontaneous loss), and a considerable number of women still report dissatisfaction with the family planning and reproductive health services actually available to them — underscoring that the “emerging” issues this article has traced are not simply data points trending in a favourable direction, but a continuing agenda for both state policy and sociological attention.