The richer the district, the poorer the sex ratio

By Durga Chandran

A study by the Gokhale Institute of Politics and Economics establishes a clear correlation between the number of sonography centres and decline in child sex ratio in Maharashtra. The average sex ratio for districts with more than 100 sonography centres is 901 and for districts with less than 100 sonography centres it is 937

Despite the implementation of the amended Pre-Conception and Pre-Natal Diagnostic Techniques Act (2003), there has been a steady decline in India's female sex ratio. Census 2001 data reveals that the number of girls per 1,000 boys in the 0-6 age-group dropped from 945 to 927 between 1991 and 2001. In some states, the sex ratio declined to less than 900 girls per 1,000 boys; in certain districts the ratio is below 700 girls per 1,000 boys.

In spite of all the rules and regulations formulated as part of the amended PCPNDT Act (2003), studies show that medical practitioners continue to disclose the sex of the foetus to parents, thereby facilitating the elimination of unwanted children through abortions. The number of ultrasound clinics too has multiplied over the years.

Keeping these factors in mind, the Ministry of Health and Family Welfare, in 2004, initiated surveys in selected states to study the functioning of ultrasound sonography centres in detail and to understand the various issues involved in their functioning so that appropriate action can be taken to strengthen the implementation of the Act.

Population research centres in Maharashtra, Punjab, Haryana, Karnataka, Uttar Pradesh, Gujarat, New Delhi and Andhra Pradesh were entrusted with the task of conducting separate surveys in their respective states, to assess the extent and use of ultrasound machines in the country. A survey of sonography centres was done mainly to determine the extent of 'untrained' ownership and the purposes for which the sonographies were carried out.

Researchers at the Gokhale Institute of Politics and Economics, Pune, were able to establish a direct link between the availability of sonography centres and a decline in the female sex ratio between 1991 and 2001 in Maharashtra. Although no clear pattern in terms of the relationship between number of sonography centres and child sex ratio emerged in the other states, it was evident that the centres were clearly not functioning according to the guidelines set out in the amended PCPNDT Act (2003).

Findings of the survey on ultrasound sonography centres

Maharashtra

As of September 30, 2004, Maharashtra had 4,345 ultrasound sonography clinics/centres unevenly distributed in its 35 districts, says the report 'A Study of Ultrasound Sonography Centres in Maharashtra' prepared by the Population Research Centre (PRC), Gokhale Institute of Politics and Economics, Pune.

According to the report, Maharashtra's female sex ratio has declined by 29 points from 946 in 1991 to 917 in 2001. In the same period, sonography centres have mushroomed all over the country including Maharashtra. The study says: "The correlation between the number of sonography centres and decline in child sex ratio is positive and statistically significant.... the higher the number of sonography centres in the districts, the higher the decline in child sex ratio in the districts."

The report reveals that 78% of sonography clinics are registered in the 'rich' western Maharashtra districts of Mumbai, Pune, Nashik, Sangli and Kolhapur -- the very regions that witnessed a decline in female sex ratio.

"Maharashtra has the most number of sonography centres in the country. The decline in the female sex ratio is the consequence of availability of sonography centres, a preference for sons and capacity to pay," say Sanjeevani Mulay and R Nagarajan, both readers at the Gokhale Institute.

The study also showed that districts with more than 100 sonography centres had a distinctly lower child sex ratio than districts with less than 100 sonography centres. The average sex ratio for districts with more than 100 sonography centres is 901 and for districts with less than 100 sonography centres it is 937.

The study explains that this is a rough indication of the link between higher availability of sonography centres and a decline in child sex ratio. Gadchiroli district with the smallest number of sonography centres (five) has the highest female sex ratio (974) in the state. Four districts -- Gadchiroli, Gondiya, Nandurbar and Bhandara -- with a fewer number of sonography centres (less than 20) have a healthier child sex ratio (958 and above).

Analysis of district-wise qualifications of owners of sonography centres reveals that the number of centres owned by untrained persons is much higher in western Maharashtra compared to other parts of the state. The number of centres owned by persons specialised in Indian systems of medicine (ayurveda, unani, siddha and homoeopathy: AYUSH) is also higher in western Maharashtra compared to other parts of Maharashtra.

A majority of sonography centres within municipal corporation limits are owned mainly by trained doctors; AYUSH doctors usually run sonography centres outside municipal corporation limits. AYUSH doctors appear to exclusively operate in smaller towns and interior areas of the districts of western Maharashtra.

It is also observed that 80% of owners have fixed machines; only 12% use mobile machines. At 'trained' centres, only 7% use mobile machines; the number increases to 25% for 'untrained' centres, indicating a tendency among untrained owners to make use of a 'mobile' facility in the absence of capacity to invest. Studies in various parts of the country have also observed that mobile facilities are mostly used to carry out illegal sex-determination tests and abort female foetuses.

Data on 'year of installation' shows that 'untrained' ownership increased remarkably after 2002, pointing to the fact that these people must have been operating even before registration, and that new people must have benefited from the 'mobile' facility and registration with the help of an appointed person.

Finally, the study notes that the worst situation is in the area of maintenance of records. Nearly 15% of centres failed to maintain any sort of records. Similarly, at the level of the appropriate authorities (appointed in accordance with the PCPNDT Act), many lapses were observed. In only 45% of cases were supervisory visits regular.

Karnataka

'Functioning of Ultrasound Sonography Centres in Karnataka', a study conducted by the Population Research Centre at the Institute of Social and Economic Change (ISEC), Bangalore, reveals that as of December 31, 2003, there were 1,621 ultrasound sonography centres in Karnataka for which registration had been granted.

The study states that the distribution of sonography centres is uneven across Karnataka's 27 districts. Most of these centres are located in urban divisions, hinting at the trend of increased sex-determination testing and sex-selective abortions in urban areas.

While 46% of sonography centres are registered in Bangalore division, Belgaum division and Mysore division each account for one-fifth of centres in the state. Gulbarga division accounts for 11% of the sonography centres. It is interesting to note that just four districts (out of 27) together account for 50% of the sonography centres. Belgaum district, which is adjacent to western Maharashtra -- where the child sex ratio is extremely low -- ranks next to Bangalore Urban district in terms of the number of sonography centres, and has the lowest sex ratio in the state.

The study also highlights the lack of maintenance of information about sonography centres by state authorities. It adds that in spite of the existence of the PNDT Act, in 26% of the centres neither the owner nor the main operator were qualified to do the scans.

Around 80% of the centres have fixed machines, 17% on-call machines and 4% mobile machines. Almost one-fifth of the centres have either mobile or on-call machines. This might be an indication that machines are being taken to remote areas to carry out tests. Possession of on-call/mobile machines is higher among untrained owners than it is among trained owners.

It is seen that most centres (both qualified and unqualified ownership) have data on tests that were carried out a year prior to the survey. The data has been classified into 'obstetric' and 'non-obstetric' cases. However, it is largely incomplete.

The report says: "Whether lack of proper records is due to ignorance or due to deliberate fudging of crucial information requires more attention. Furthermore, some owners even refused to give any kind of information regarding their centres. A few other centres could not be located at their registered location. All these findings point to the lack of proper implementation of the Act in Karnataka."

The study concludes that on the whole, implementation of the PNDT Act in Karnataka is weak. It identifies a number of loopholes as far as implementation is concerned, such as poor maintenance of records at the scanning centres, lack of maintenance of monthly reports, lack of qualified operators performing the scans, and lack of supervisory visits by the appropriate authorities.

A total of 197 centres with untrained owners, 56 centres with trained owners and 46 centres owned by AYUSH doctors formed the basis of this analysis. Almost 50% of centres have more than one operator for the scanning machine. However, many do not visit the hospital despite the fact that their names are listed as operators. This could have led to untrained persons operating the machines under the pretext of being trained operators.

Gujarat

The study titled 'A Survey of Centres Using Ultrasound Machines in the State of Gujarat', conducted by the Population Research Centre, M S University of Baroda, shows that there are about 1,735 registered centres/clinics using ultrasound machines in the state of Gujarat.

An analysis of available records of these centres reveals that 95% of registered centres using ultrasound machines are owned by the private sector, while the government manages the remaining 5%. More than 99% of registered centres follow the allopathy system of medicine; less than 1% follow other systems of medicine.

Over four-fifths of registered centres (83%) were found to possess a fixed machine, 1% have mobile machines and another 3% provide 'on-call' services. For the rest of the centres, the necessary information is unavailable.

The study reveals that about 16% of registered centres appear to have owners who are not adequately qualified, according to the Act. "In fact, this proportion increases to about 25% if those centres where qualification of the owner is not available are considered centres with untrained doctors," adds the report.

A majority of owners report that they use the machine only at their own clinics; a few say they provide on-call services. Surprisingly, some stated that they also use their machines at clinics that are not registered under the PCPNDT Act.

The results further showed that less than half of the surveyed centres have a qualified person operating the ultrasound machine, ie, a radiologist, gynaecologist, or a person with an MBBS or higher degree with requisite training/experience in sonography.

Regarding the demand for ultrasonography for screening, it was found that about 607 patients were examined by ultrasonography in the one year prior to the survey. Of them, almost half were for obstetric purposes indicating that use of ultrasonography during pregnancy is high probably due to the fact that it is useful in monitoring the development of a pregnancy, as reported by many gynaecologists.

The report however warns that data on some patients who underwent sonographies needs to be interpreted with caution, as records are not well maintained and often the figures given are estimates or approximations.

The sharpest declines in sex ratio for child population are reported from Himachal Pradesh, Punjab, Haryana, Chandigarh, Delhi and western Uttar Pradesh where abortions of female foetuses are known to be widely practised.

"Today, ultrasound is the sex-selective technology that is widespread in most prosperous states. The reasons are easy to define -- prosperity ensured better infrastructure, more machines and more doctors to perform the tests. People had money-power to pay for the technology and, of course, as infrastructure improved, people could access the clinics easily. All this has made foeticide rampant," says leading demographer Ashish Bose.

InfoChange News & Features, January 2006