Doctors have contributed to the declining sex ratio in India. Only social reforms and effective implementation of the PCPNDT Act will decrease sex selective abortions
Sheela Saravanan | February 17, 2017
Sex selection for some feminists is ‘sexist’ and sex selective abortion considered a form of ‘femicide’, regardless of the preferred sex orientation, the location of the practice, or the birth order of the child.
India’s child sex ratio (CSR), the primary indicator of missing girls in India, is the lowest since independence at 918 girls per 1,000 boys (census 2011). The CSR in India declined from 945 in 1991 to 927 in 2001. The ratio of 950-970 girls per 1,000 boys is considered normal, according to population studies experts. Prenatal diagnosis and selective abortion is gaining relevance with advances in assisted reproductive technologies (ART), which offer sophisticated methods of sex determination at the embryo stage and enable non-invasive methods of foetal sex determination in the first trimester (from six weeks) of pregnancy.
In India, medical practitioners have played a major role in the elimination of girls. Doctors’ role in sex determination and sex selective abortions in India in the 1970s and the 80s is well documented by feminists. Sabu George, an academic crusader against sex selective abortions, has written extensively against the role of medical practitioners in promoting this sort of femicide. According to him, “Traditional son preference has become intense daughter hatred in India due to a lack of medical ethics” (George 2006: 607).
The fieldwork of my ongoing research project [titled ‘Wunschkinder (desired children) in Germany and India as a context leading to prenatal genetic diagnosis and selective abortions’ (2015-2018)] includes interviews with gynaecologists/obstetricians, pregnant women and their family members. I interviewed seven gynaecologists (three in Delhi, two in Maharashtra and two in Odisha) on sex selective abortions, their opinion on sex determination, their patients’ perceptions regarding the Pre-Conception and Pre-Natal Diagnostic Techniques (PCPNDT) Act 1994 and its implementation.
I observed that many people continue to desire for a boy but are restricted by law to achieve this. Doctors want to oblige the desires of their patients to conduct sex selective abortions but are not doing it fearing legal implications. Media too plays an active role in exposing such information. Hence doctors also fear shaming by society. Publicly, people tend to strongly criticise sex selection even though they themselves may be involved in such practices. Medical practitioners feel that a strict law implementation has been effective in reducing sex determination and selective abortions. However, some people find ways as some doctors are willing to violate the law. Some people go abroad for this purpose. The medical fraternity seems to know the doctors who violate the law but prefer to be a silent spectator. Against this backdrop, the medical fraternity makes impractical suggestions to liberalise the law and to criminalise people for sex determination instead of the doctors.
Boy continues to be favoured
“People say they want to balance their families. But they don’t abort second boys. Only the second girls are aborted. If they have one male child, they don’t mind having another male child. This happens especially in business class families,” one of the doctors in Delhi said. “More people from the educated class ask for sex determination. If they have one female child, they don’t want another female child,” he added.
Data also suggests that the prosperous and/or educated people more often misuse prenatal technologies to eliminate girls. “If the patient asks five doctors and all of them say, ‘No, we don’t do it’, then where will they go?” asked a doctor practising in Maharashtra. A doctor in Delhi said, “Rich people approach us for the in-vitro fertilisation [IVF] treatment so that they can have a boy child [through pre-implantation genetic diagnosis or PGD].” The doctor knows couples who went to Thailand and Singapore for PGD. However, one doctor in Delhi observed that some people, whom she referred as ‘the new educated generation’, “don’t want sex selection as they are indifferent to the sex of the child. They just want a healthy child and are not concerned if it’s a boy or a girl”.
Doctors fear the law and shaming
Doctors say that the strict law implementation has controlled the extent of the practice of sex determination. A possible absence of the PCPNDT Act would have led to at least 1,06,000 fewer girl children in India (Nandi and Deolalikar 2013). According to a gynaecologist in Maharashtra, if 20 doctors were involved in the practice previously, the number has reduced to two as the law implementation has tightened in the last couple of years. He mentioned the Beed episode of 2012, where few doctors were found disposing female foetuses by feeding them to dogs to destroy evidence of female foeticide. After the incident was highlighted by media, doctors have become vigilant. “Doctors have now realised that it is very difficult to do it and if you do it illegally there is nobody who can support you,” he said.
A doctor in Delhi said “Sting operations take place and I strictly refuse because I don’t want to get into trouble.”
A dip in the sex ratio in favour of boys in Odisha has become a cause of concern. In 2007, at least 60 female foetuses were found in a pit used to dump medical waste near a nursing home in Nayagarh. The state government ordered stringent action against nursing homes and clinics for violating the PCPNDT Act. Gynaecologists from Odisha were scared to even speak to me as they thought that I was a part of some sting operation. The medical fraternity here is the main violator of the law, just as it was experienced some decades ago in Delhi, Punjab and Haryana.
Persistent violation of the law by doctors
Despite strict implementation of the law and sting operations around the country some doctors continue to violate the law. Every other day there are reports on aborted girl foetuses being found in plastic bags or jars dumped in rivers, rubbish bins or sewage drains.
One gynaecologist from Maharashtra said that doctors doing sex determination tests charge high fee ('60,000-1,00,000) because of the risk involved. This makes it unaffordable to most (80%) of the patients. “Doctors who are still doing it are under the impression that they have strong political backing; they think they can get away with everything. Unless and until these doctors have the fear of getting arrested and getting discriminated in the society, they will continue,” he said.
According to the PCPNDT Act, every genetic counselling centre, genetic laboratory, genetic clinic, ultrasound clinic and imaging centre shall maintain a register showing, in serial order, the names and addresses of the men or women given genetic counselling, subjected to pre-natal diagnostic procedures or pre-natal diagnostic tests, the names of their spouses or fathers and the date on which they first reported for such counselling, procedure or test. Furthermore, any person conducting ultrasonography/image scanning on a pregnant woman shall give a declaration on each report on ultrasonography/image scanning that he/she has neither detected nor disclosed the sex of the foetus of the pregnant woman to anybody. The pregnant woman should declare that she does not want to know the sex of her foetus before undergoing ultrasonography/image scanning.
All doctors complained about the task of maintaining these records. One doctor from Maharashtra said “Due to the record keeping requirement, the cost of ultrasound has increased from '400 to '800. A person has to be employed specifically for this purpose and paid a salary of '8,000-10,000 per month. Additional investment has to be made for internet and other requirements,” he said. He said his sonologist is constantly worried that his machine can be confiscated anytime leaving him unemployed.
Frustrated with the intense reporting system, one gynaecologist in Delhi said, “Why is the government harassing sincere doctors? Go and catch the doctors who are actually doing it.”
It is surprising that some of the doctors I interviewed admitted to knowing doctors who are involved in this illegal practice. “I know them very well as they are my good friends,” said one doctor in Maharashtra. He supported those involved in sex selective abortions: “All of the doctors involved in sex determination have one or two girls themselves and hence know the plight of having a girl child.” Moreover, they are doing it not because they intend to terminate the (girl) child, but because “patients force them; they pressurise them, beg them in some way or the other and convince them to do it”.
He said that the government focuses on gynaecologists and sonography clinics. This should change because it is the patients who “force, pressurise and beg” doctors to determine the sex of the foetus to conduct selective abortions.
Liberal use of sex determination
The legal system should target the patients instead of the doctors. The doctor claims that this suggestion is jointly proposed by a group of 400-500 medical practitioners who are actively involved in making suggestions for the Beti Bachao Andolan. “It is the patients who desire to have a boy child and want to terminate a female foetus and hence they are the culprits and not the doctors,” he said.
He proposes for sex determination to be made liberal and suggests that pregnancies be tracked thereafter. Any pregnancy declared to be a girl child and not registered in an aangawadi a year later should be tracked and the guilty should be punished. With this proposition, foetal sex would be recorded in clinics and hospitals.
One of my main concerns here is that most of the pregnancies detected with a girl child may not even get registered in clinics and hence cannot be tracked. The other concern is that not all pregnancies result in live births and many of the foetuses declared as girls can be forced to be aborted and reported as a ‘miscarriage’.
The doctor suggests that the focus should shift from sex determination to stopping termination of pregnancies. But in India, most abortions are unrecorded as they are conducted illegally. There are several places where people can go for abortions, so terminations of pregnancies can’t be traced effectively. Even migration can deter the detection of such abortions. People migrate and the babies declared as a girl child in the womb can be untraceable after a year. Sex selective abortion is already a common cause for induced and unsafe abortions by inadequately trained professionals. It will continue to increase endangering the health, and possibly the life, of the mother and the unborn baby. With increasing use of abortion pills, its consumption can be forced on women causing miscarriages and consequent health risks.
Moreover, the doctors seem to be unclear about who should be considered as the perpetrators in this offence – the mother or her family members. In their desperation to shift the blame from themselves to common people, the doctor seems to support this irrational, thoughtless proposition of targeting patients. Doctors in India tend to think from an ‘individualistic’ and one can say ‘selfish’ perspective rather than from a ‘social justice’ context.
The medical fraternity continues to violate the law and as this continues the implementation mechanism will remain ineffective. The medical fraternity, rather than blaming the implementation mechanism or the people for sex determination, should do their duty not only as honest citizens of India but also as educated, elite and prosperous individuals. They must dissuade their colleagues from conducting sex determination tests and report doctors who are indulging in this practice. Sabu George says that “physicians who perform prenatal diagnosis purely to identify foetal sex, or those who disclose foetal sex when that is unrelated to the foetus’s medical condition, should be disciplined by the medical licensing authorities” (George 2006: 607).
There is increasing access, affordability and awareness about reproductive technologies, while social reforms to transform gender-biased mindsets are progressing slowly. The government is taking measures to restrict clinics from determining sex but it’s a challenge to be able to maintain pace with the rapid use of technology.
A strong social movement is required along with the implementation of the PCPNDT Act. Additionally it is important that women are empowered. Women need to be supported legally and financially if they wish to resist repeated pregnancies or abortions under family or social pressures. Although it is well known that some women are forced into sex determination by in-laws and husbands, there is no law supporting women who oppose sex determination. There is no economic support for women who want to separate from their husbands for this reason.
I would like to acknowledge the contribution of Alicia Finger and Jonas Wachinger in assisting me with the thematic analysis of the interviews I conducted in India.
George S.M. (2006) Millions of missing girls: from fetal sexing to high technology sex selection in India. Prenatal Diagnosis, 26: 604–609.
Nandi, A and Deolalikar, A. B. ‘Does a Legal Ban on Sex-selective Abortions Improve Child Sex Ratios? Evidence from a Policy Change in India’, Journal of Development Economics 103 (2013): 216-228.
Sheela Saravanan is with the department of anthropology, University of Heidelberg, Germany.
(The column appears in the February 16-28, 2017 issue)
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