Missing female patients: an observational analysis of sex ratio among outpatients in a referral tertiary care public hospital in India

OBJECTIVE: To investigate gender discrimination in access to healthcare and its relationship with the patient’s age and distance from the healthcare facility. DESIGN AND SETTING: An observational study based on outpatient data from a large referral public hospital in Delhi, India. PARTICIPANTS: Confirmed clinical appointments. PRIMARY AND SECONDARY OUTCOME MEASURES: Estimates from the logistic regression are used to compute sex ratios (male/female) of patient visits with respect to distance from the hospital and age. Missing female patients for each state—a measure of the extent of gender discrimination—is computed as the difference in the actual number of female patients who came from each state and the number of female patients that should have visited the hospital had male and female patients come in the same proportion as the sex ratio of the overall population from the 2011 census. RESULTS: Of 2377028 outpatient visits, excluding obstetrics and gynaecology patients, the overall sex ratio was 1.69 male to one female visit. Sex ratios, adjusted for age and hospital department, increased with distance. The ratio was 1.41 for Delhi, where the facility is located; 1.70 for Haryana, an adjoining state; 1.98 for Uttar Pradesh, a state further away; and 2.37 for Bihar, the state furthest from Delhi. The sex ratios had a U-shaped relationship with age: 1.93 for 0–18 years, 2.01 for 19–30 years, and 1.75 for 60 years or over compared with 1.43 and 1.40 for the age groups 31–44 and 45–59 years, respectively. We estimate there were 402 722 missing female outpatient visits from these four states, which is 49% of the total female outpatient visits for these four states. CONCLUSION: We found gender discrimination in access to healthcare, which was worse for female patients who were in the younger and older age groups, and for those who lived at increasing distances from the hospital.