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By Lalitha Sridhar The PCPNDT Act prohibits sex selection by any means, before or after conception. But, as one survey in Chennai of 29 ultrasound clinics found, for the medical fraternity it's business as usual
“Women patronise scan centres; they want to know the sex of the child. So many of them come without any pressure from their husbands or mothers-in-law. Doctors who promote scanning to determine the sex of the foetus are only fulfilling a demand in society.” So says Dr K R Balasubramaniam, president of the Tamil Nadu Medical Council. His blatant defence is only one aspect of the collusion between the medical lobby and Indian legislators in not preventing the death of that most vulnerable being in India -- the female foetus. The Pre-Conception and Pre-Natal Diagnostic Techniques (Prohibition of Sex Selection) Act and Rules 1994 (as amended up to 2002) (the PCPNDT Act) mandates that sex selection by any person, by any means, before or after conception, is prohibited. Then there is the legally binding Code of Medical Ethics, constituted by the Indian Parliament in the Medical Council Act, 1956, that many doctors conveniently ignore. Doctors are legally bound to report medical malpractice. Says Dr Puneet Bedi, a Delhi-based foetal medicine specialist and anti-foeticide activist: “In medical practice, by the very nature of the profession, everything which is unethical is also illegal.” To the contention that the medical fraternity is colluding in the practice of female foeticide, Dr Balasubramaniam says: “Doctors are not a special tribe removed from society. Therefore, the faults of society will also be found among them.” “Clearly,” says a visibly angry Mina Swaminathan, gender activist, “Dr Balasubramaniam neither knows law nor medicine. Given that he represents doctors in Tamil Nadu and speaks for them, we can have a fair idea of the degree of medical malpractice that exists.” “Female foeticide is a crime against humanity,” says Bedi. “Doctors as a community are involved. The only surprise for people like us who have been talking about the problem for some time is that people are surprised. Statistics, with all their limitations, ultimately reflect social realities. The zeal with which female foeticide has been pursued in the last few decades had to get reflected in the national census.” The 2001 census registered a decline in the child sex ratio in 80% of the districts in India. The juvenile sex ratio, which stood at 976 in 1961, fell to 927 in 2001, for the country as a whole. Twenty of the 30 districts in Tamil Nadu have a sex ratio at birth lower than the biological sex ratio. According to government statistics, there are 2,379 registered scan centres in Tamil Nadu alone. This, in a country that critically lacks medical health infrastructure. In Chennai itself, 147 private nursing homes are allowed to carry out medical termination of pregnancy and sterilisation. Seizure of equipment/machines for non-registration usually results in the release of machines after payment of a fine. After that, it’s business as usual. There is virtually no monitoring of the other requirements of the Act. Ninety per cent of deliveries in Tamil Nadu are institutional. Yet, the sex ratio of children at birth is not registered or made available in the public domain. In a surprise survey of 29 ultrasound clinics in Chennai, by activists from the Campaign Against Sex Selective Abortion (CASSA), staff at one prominent hospital said they were unaware that any forms had to be filled out by patients. Of the 29, only one maintained the required records. The PCPNDT Act mandates that any person conducting ultrasonography or any other pre-natal diagnostic technique must maintain proper records. The Act requires the filling up of a written form, duly signed by the expectant mother, as to why she has sought diagnosis. Violations are punishable by imprisonment and a fine. But one doctor said that during her three-year career she had never mentioned the MTP (Medical Termination of Pregnancy) Act to any of her patients, as she is legally required to when an abortion is performed. A register giving reasons for termination of pregnancy and the period thereof also has to be maintained. But it rarely is. At another facility, the reception desk claimed abortions were being performed. But the gynaecologist said they were not. One practitioner is on a National Monitoring and Reporting Committee for violations in the Code of Medical Ethics, but receives numerous ‘standard’ referrals for ultrasonography every day. Another facility had the 4D TV screen facing the patient for a full view of the examination. One reputed hospital said 99% of its patients wanted to know the sex of the child. All denied revealing it. Only one ultrasonologist boasted that he could determine the sex of the foetus at 45 days! Near the one-room clinic of a medical graduate, in a residential suburb of Chennai, a banana-seller told visitors from a non-governmental organisation (NGO): “Abortion? Go there (pointing to clinic).” The National Health Policy makes no mention of gender, women’s health or monitory systems. The Tamil Nadu government has not constituted a supervisory board, as mandated by the PCPNDT Act, to monitor the implementation of the Act and Rules. Legislation has, for years, lagged behind technology. Already, the abortion pill (part of the state-initiated family welfare programme) makes surgical termination of pregnancy redundant. New non-invasive drugs like antiprogestogen-mifepristone derivatives, which, studies have shown, are 85-97% effective, are available over the counter. The pressure to enforce the PCPNDT Act seems to have resulted in the opening out of abortion options. The MTP Act offers protection to registered medical practitioners against any legal or criminal proceedings arising out of harm or injury to women seeking abortions, unless the contrary is proved. Studies indicate that the risk of death is seven to ten times higher for women who wait until the second trimester to terminate their pregnancies. Sex selective abortions are all second trimester abortions. Dr Saradha Jain, secretary of the Indian Medical Association, warns that the risk of maternal morbidity/mortality needs to be given as much attention as the negation of women’s rights to better health. Says P Phavalam, state-level convenor of CASSA: “The female foetus is considered a disease and elimination is done as a service to mankind.” The three chief pre-natal diagnostic tests that are being used to determine the sex of a foetus (sexing) are amniocentesis, chronic villi biopsy (CVB) and ultrasonography. Amniocentesis is meant to be used in high-risk pregnancies, in women over 35 years. This embryonic pre-natal test requires the removal of 15-20 ml of amniotic fluid. The cells have to be cultured for three weeks, or else there is an inaccuracy rate of 10-20%. CVB is meant to diagnose inherited diseases like thalassaemia, cystic fibrosis and muscular dystrophy. Ultrasonography is the most commonly used technique. It is non-invasive and can identify upto 50% of abnormalities related to the central nervous system of the foetus. But sexing has become its preferred application. Depending on the ultrasonologist’s expertise, chances of a correct prediction are 95-96%, with greater accuracy as the pregnancy advances. If the foetus is female, a second trimester, even a third trimester abortion is carried out either by a doctor or a quack. Says Bedi: “In societies like China and India, infanticide has been practised with all kinds of social sanction. The act of abortion, even the term ‘foeticide’ is designed to de-sensitise, clinically, the act of foetal murder. The MTP Act further trivialised the issue of foeticide. There has been an inability to discuss the issue of foeticide without the larger debate on abortion, which is legally allowed and has been seen as a triumph of the women’s rights movement in the country.” Some doctors feel that the resultant de-sensitisation has meant, unfortunately, that foeticide can no longer be separated from gender unspecified abortions. Bedi adds: “We may have to, for some time at least, revive the guilt of foetal murder. It would be calling a spade a spade.” An excerpt from the Hippocratic oath, written 2,300 years ago, reads like an accurate prophecy of doom: “Our mistakes are not discovered by the patient (or their kin in case of the deceased)…and even if they are…they may whimper but rarely scream…and the worst penalty a doctor has to pay for his sins is disgrace…and it is surprising how little it (disgrace) bothers those who are used to it.” (Lalitha Sridhar is a Chennai-based freelance journalist) InfoChange News & Features, August 2004
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