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BACKGROUND: A reduction in sex ratio at live birth has been proposed as a sentinel health indicator that can be used to monitor the health of populations. OBJECTIVE: To test the hypothesis that a lower sex ratio is associated with adverse national population health using the prevalences of HIV and tuberculosis as measures of societal well-being. METHODS: An ecological study design using routinely collected data and adjusting for potential confounding factors. RESULTS: The mean global sex ratio was 1.05. There was marked heterogeneity in the sex ratio between different global regions (p<0.0001). Those regions with the highest prevalences of HIV infection had lower sex ratios, with the value for the highest quartile being 0.022 (95% CIs CI 0.013 to 0.031) lower than the lowest quartile. Similarly, those areas with the highest quartile of tuberculosis infection had a sex ratio of 0.016 (95% CI 0.004 to 0.028) lower than those in the lowest quartile. Similar results were observed in a subgroup analysis limited to countries from the African continent. CONCLUSIONS: The data are consistent with the hypothesis that a reduced sex ratio at live birth is a potential sentinel health indicator of lower population health. However, these data do not demonstrate either a casual relationship or reveal any biological mechanisms that may account for these observations.
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