Rough estimates, backed up by the scenes at clinics and orphanages, suggest there may be millions of "missing" women and girls due to families' preference for boys.
LAHORE, Pakistan -- Dr. Saida Zafar, an 86-year-old gynecologist at the Race View Clinic, hovers over a female patient as she performs an ultrasound on her pregnant belly.
Within minutes, the patient asks a question that haunts most pregnant women in Pakistan, "Is it a boy, doctor?"
It's not a boy. The woman is expecting a girl.
Zafar says that when she finds herself in this position, she has to balance the patient's right to hear the truth against her own desire to save the female fetus from the risk of sex-selective abortion, as many families here prefer sons. So, often, she lies.
"I tell everybody, 'You are having a boy,"' Dr. Zafar tells us in English, so the patient won't understand.
Other doctors at the clinic face this same challenge every day, and many share similar frustrations.
"Only for the first child [do] I tell them if it's a girl or a boy. But after that, if it's a boy, it's alright, but if it's a girl, I don't say anything," says Dr. Ain-ul-Ghazala, 58, another gynecologist at the clinic.
Zafar says she withholds the sex of female babies from expecting mothers, as the news will almost always lead to cries of sorrow. And those cries can lead to action, as evident in Pakistan's sex ratio at birth.
Globally, a country's sex ratio can naturally range as high as 104 or 105 newborn male children for every 100 newborn female children. But, as in neighboring India, Pakistan's sex ratio is thought to exceed even that, suggesting that such anecdotal experiences as Dr. Zafar's are part of a larger trend.
According to one estimate by the CIA World Factbook, Pakistan currently has 6 percent more males than females. But Stephan Klasen, the Chair of Development Economics at the University of Goettingen in Germany, says he suspects the problem is actually much worse. Klasen studies the phenomenon of "missing girls," a term he uses for the shortage of girls in some countries, typically caused by parents' preference for boys. And because Pakistan hasn't had a census in 14 years, which typically provides the most reliable data, he says he's concerned that the real disparity between the sexes in Pakistan might be even higher.
"The main factors causing this 'missing women,'" phenomenon, he says, "are basically sex-selective abortions and female neglect in early age, mostly neglected healthcare."
Visiting the clinic on another day, we go to the second floor to watch the doctors and nurses deliver a baby by caesarian section. The mother lies nervously on the operating table. When the doctors pull out the baby, she asks excitedly, "What's the sex of the baby?"
"It's a girl," responds Dr. Ain-ul-Ghazala, the gynecologist, in a quiet voice.
The mother's smile disappears as she turns her face to the wall. This is her second daughter.
The doctors clean the baby, wrap her in a blanket, and take her to the nursery, where families usually gather to see their child for the first time. An hour later, a large group comes here to celebrate the birth of a boy. A few cribs away, the newborn girl lays crying. The doctor explains that no one has yet come to see her because the family is still in mourning.
"The mother is upset, it's the second daughter, they expected a son," Ain-ul-Ghazala says, "The mother was crying, it was quite upsetting."
Her reaction is hardly unusual here, "It's still a bad thing to have girls," Zafar explains.
Still, she says she's not too worried about the family's reaction. She's used to it. In a few days, she predicts, the family will come to terms with the birth of their daughter and learn to love her.
But families who walk out of clinics like Race View don't always come to terms with the birth of their daughter. Bilquis Edhi, a 64-year-old woman we spoke to who runs an orphanage in Karachi, has seen proof of that first hand.
Along with her husband, Abdul Sattar Edhi, Bilquis runs their orphanage in the bustling Saddar Town neighborhood, and a quick glance at the shelter makes clear that it's mostly girls who get left here.
"Since the beginning, more girls come here than boys," she says. "I think people don't like to give boys away."
These girls are often the lucky ones.
At the entrance of the orphanage is a silver-framed crib, where parents can leave unwanted children, no questions asked. Above it, an Urdu poster reads, "Don't kill the baby, leave the baby alive in the cradle."
Edhi says she sometimes finds dead baby girls in the crib in front of the shelter. She suspects that families worry that, if they leave their daughter alive, someone will come looking for them to ask why they abandoned the child, or even ask them to take her back.
She pulls out a photo of a baby girl that had been left in the crib recently. "Look, they have burned her to death," she says. The photo shows a newborn, its umbilical cord still attached, whose tiny body is fully blackened.
"Pakistan is more or less a failed state. The government is not doing anything about this problem."
But, even amid this despair, there is some hope. Edhi proudly notes that her orphanage has helped almost 20,000 boys and girls. "The children I have taken care of have become engineers, doctors, believers of Quran, good human beings," she tells me. "I have even sent girls to America," she adds with a smile.