Patriarchal norms and reproductive vulnerability: association between son preference and high-risk fertility behaviour in India

BACKGROUND: Son preference, deeply entrenched in India's sociocultural fabric, remains a critical yet under-examined structural driver of high-risk fertility behaviour (HRFB), defined as early childbearing (< 18 years), late childbearing (≥ 35 years), high parity (≥ 4 births), and short birth intervals (≤ 24 months). While national fertility has declined to replacement level, HRFB persists. DATA AND METHODS: Using nationally representative data from the National Family Health Survey-5 (2019-21), we analysed 229,680 women aged 15-49 with recent live births. Son preference was defined as a stated ideal number of boys exceeding that of girls. HRFB was categorized as any and multiple risks. We employed multivariable logistic regression, multinomial logistic regression, and Fairlie decomposition analysis to quantify associations and decompose disparities. RESULTS: Women with son preference had 30% higher odds of any HRFB (AOR = 1.30, 95% CI: 1.27-1.34). Women with three or more daughters had higher odds of HRFB (AOR = 7.59, 95% CI: 7.26-7.93). Maternal age (≥ 35 years) was associated with higher odds of HRFB (AOR = 5.03), while larger household size with more than eight members was associated with higher odds of HRFB (AOR = 1.66). Fairlie decomposition revealed that 62.9% of the HRFB gap between women with and without son preference is explained by measurable factors, including living daughters (26.96%), maternal education (20.49%), and household wealth index (14.47%). CONCLUSION: Son preference remains a significant structural correlate of HRFB in India. Addressing persistent gender-biased fertility norms requires integrating girl-centred education, postpartum contraception after the birth of daughters, and gender-transformative health messaging within programmes such as Mission Parivar Vikas.