“In 1982, we did the first ultrasound in North India in this clinic,” says senior radiologist Dr (Col) CS Pant at his diagnostic centre in Green Park, south Delhi. “Now I do [them] very seldom.”
Dr Pant, a former president of the Indian Radiological and Imaging Association, says he dreads doing pregnancy ultrasounds because it has become a potential source of harassment. He and a colleague, Dr Vaneeta Kapur, present a Kafkaesque picture of a system revolving around forms filled in quadruplicate, an inspector raj, and an obsession with trivial details. They say it is a system that has lost sight of the bigger picture.
What is that bigger picture?
The terribly unbalanced child sex ratio in the country, which is going from bad to worse. Back in 1981, there were 962 girls in the age group of 0-6 years for every thousands boys. This ratio fell to 945 girls in 1991, then to 927 girls in 2001, and to 918 girls by the time of the 2011 Census.
To arrest this slide, the authorities had promulgated the Pre-conception and Pre-Natal Diagnostic Techniques (Prohibition of Sex Selection) Act in 1994. There were concerns that ultrasound technologies were being used to determine the sex of the unborn child and abort the female foetus, so the 1994 law made it illegal for medical practitioners to reveal the sex of a foetus.
But, the law didn’t work as well as was hoped, as the Census figures over the years show.
Public health activists say this is because the government didn’t implement the law properly – sex determination and female foeticide continue because of insufficient monitoring of medical practitioners. Radiologists and gynaecologists, on the other hand, claim it is because the law was misdirected from the very beginning – it held the medical fraternity responsible for a problem that is manifestly societal.
The PNDT Act mandates that all ultrasound facilities must be registered and medical practitioners must maintain records of every scan of a pregnant women. It states that pre-natal diagnostic techniques can be used only to detect “genetic abnormalities or metabolic disorders or chromosomal abnormalities or certain congenital malformations or sex-linked disorders”.
“The system is barking up the wrong tree,” Dr Kapur said. “It is parents who abort [sex selectively] who are committing the crime.”
This attitude may explain why some doctors like Dr Anjila Aneja, Director and Head of Obstetrics & Gynaecology at Fortis La Femme, back a controversial suggestion made by Maneka Gandhi. On February 1, the Union Minister of Women and Child Development had declared in Jaipur that the gender of the child must be compulsorily determined and registered and the birth tracked. Though she later clarified that this was only an “alternative view”, the idea received hearty support from the Indian Medical Association and members of the Indian Radiological and Imaging Association.
“Sex determination should be legalised,” Dr Aneja said. “Then you’ll come to know who is going to abort it [the child]. The follow-up [can be] done from our side, patient ke ghar pe.”
Bogged down in details
Among the medical fraternity’s major criticisms of the PNDT Act is its emphasis on details. There is an essential four-page “Form for Maintenance of Record in Case of Prenatal Diagnostic Test/ Procedure by Genetic Clinic/ Ultrasound Clinic/ Imaging Centre” – Form F for short – which has to be filled in triplicate and co-signed by the patient and doctor conducting an ultrasound before the procedure can be done.
Earlier this used to be done manually with carbon copies, but as of March, the form has to be submitted online onto a government database. This has been in trial mode for the past few months. The entire procedure, including filling out the correct contact information and address, along with family details, the name of the doctor referring the patient, the number of weeks of pregnancy, the name of the doctor performing the procedure, and having the patient sign the form along with the declaration that the patient does “not want to know the sex of my foetus”, has to be completed before the ultrasound is done.
In March 2015, the Indian Radiological and Imaging Association, the umbrella organisation of radiologists had written to Union Health Minister JP Nadda to complain about the PNDT Act and its Form F fixation. To quote from the letter, “The focus on foeticide has been conveniently forgotten. Nothing is done to check illegal foeticide & hence in ground reality, the one who is involved in foeticide & sex determination does a fantastic paperwork & hence scot free (sic) which is now an open secret.”
The letter continues that “the Act is so heinous that it is worst (sic) than TADA for Doctors, especially radiologists who are treated worst (sic) than hard core criminals”.
There have been other hitches in the system, from patchy internet connectivity to lack of computer-trained personnel. At a rural medical centre in Saket, south Delhi, Dr Kapur and the ultrasound room assistant Rekha Roy identify some of the other major problems they face.
“Identification documents hi nahin hai,” Roy said. “Yahaan uneducated (log) aate hain. Naam likhna nahin aatha. Anghuti lagatey hain.” Denying them an ultrasound because of that missing information means they have to go back home and come all the way back, which many can’t afford to do. “Jab aatey hain, daily salary cut hotha hai,” Roy explained.
Many patients apparently don’t have valid ID and try to use their husband’s identification documents, which is also not kosher, since those don’t bear the patient’s signature.
The stakes for the clinic performing the ultrasound are high. If the proper procedure isn’t followed or the address is incomplete or there are anomalies in a Form F, the PNDT authorities can shut down a clinic and seal the ultrasound machine. It is for the radiologist or doctor to prove their innocence, go to the court and get the machine unsealed, a process that can take months.
Roy doesn’t see the point in this obsession with forms: “PNDT se disclose nahin karte hain. Batate nahin. Phir birth karke abandon karte hain. (No-one is disclosing the sex of the baby through the PNDT Act. But then the mothers give birth to baby girls and then abandon them.)”
Money makes all the difference
At the rural medical centre, funds are also a constraint. “What do you do when there are no resources?” Dr Kapur asked. “At Fortis [La Femme] we have two people just to fill forms.” At a cost of Rs 25,000, that’s not something this rural centre can afford.
One assistant helps the doctor register the patient, prepare the report, fill and file ‘Form F’ online and control patients, who tend to get unruly when they have to wait too long, Dr Kapur says. And things do get busy. A Tuesday in mid-February saw 32 ultrasounds done by two attending doctors, working in shifts (8:30 am to 11:30 am and 12:30 pm to 2 pm), including 8 obstetric/pregnancy related ultrasounds. Dr Kapur says that from April to May, considered “peak season”, they have 40-45 ultrasounds a day.
A handwritten sign on display at the rural medical centre highlights that identification documents are a requirement, along with the standard sign in blue that sex determination tests are illegal and not conducted. That blue sign is probably the only thing in common with the decidedly more swanky Fortis La Femme in Greater Kailash-2, south Delhi.
The big difference is what money can buy. There are two employees working on shift here, whose only job is to fill and log in the Form F’s online. One of them, Pratiksha, is obviously well-versed in filling and submitting them online. She says each form takes her about 15-20 minutes to fill and submit. While the doctors have to double-check the forms in real time for any possible errors, there’s someone else who will routinely go through the files to make sure no details have been missed. It adds up to a lot of administrative work, and while there are more resources brought to bear here, the doctors still have that vaguely stressed air.
One of the older doctors says they’re not all as web-savvy, that they don’t have enough people to help them in their local clinics. There’s no time these days to worry about anything other than the administrative duties, she says, reflecting on a time when radiologists and gynaecologists would also try to counsel pregnant women. Cut to the present day when radiologists like Dr Kapur and Dr Pant both say that it is tempting to just avoid pregnancy ultrasounds altogether and focus instead on CT scans and MRI scans, which are more lucrative and less of a hassle.
Dr Pant also takes umbrage to everyone being tarred with the same brush. “We’ve spent a lifetime protecting rights, but hum logon ko criminal bana diye.”
Trips to Bangkok
Dr Jignesh Thakker, the current president of the IRIA, says the “PNDT is not going to serve any purpose for the next 100 years, unless we change the mentality of the patient vis-à-vis the girl child or the male child”. He highlights what he considers a major problem – that the government doesn’t even know how many ultrasound machines are in the market. That sale needs to be regularised, he says.
Dr Pant’s suggestion is for more stringent procedures to do with the medical termination of pregnancy. He feels authorities should scrutinise abortions carried out when the foetus is 12-16 weeks. You can’t tell the sex of the foetus till about 8 weeks, so this is the time frame when presumably the sex selection is going on.
But are we ready for that level of a nanny state? So many women just want to have control over the right to choose, so many others just want to know the sex of their unborn child.
Not that prospective parents aren’t finding out – whether by a reference to a male or female deity, or a reference to blue or pink. Incidentally, ultrasound clinics aren’t allowed to have pictures of Ganesh or Lakshmi, because they could be used to indicate the gender of their child.
Nonetheless, a young mother says that word spreads about who might share this information. When she was expecting she heard of a doctor in Defence Colony, Delhi, who would supposedly congratulate the future parents with a Jai Shri Ram or Jai Mata Di, depending on the sex of the unborn child.
She herself prevailed upon someone at a fourth or fifth health check-up in her eighth month of pregnancy, saying it was obvious she wouldn’t discriminate on the basis of the sex. Indeed, many patients who can afford to, go to Bangkok or Dubai or Singapore to find out, doctors say. Turns out, she didn’t need to spend on airfare – the blue folder she was carrying came in handy.
Dr Pant likens the PNDT Act to “an inspector raj”, saying that “PNDT authorities cannot be prosecuted, only doctors”. There was no response despite attempts to reach the PNDT authorities at the Ministry of Health and Family Welfare.
Misuse of knowledge
Not everyone agrees with the interpretation of Dr Pant, Dr Kapur and Dr Thakker.
Obstetrician Dr Anita Kaul, a senior consultant and coordinator, Foetal Medicine, at Apollo Hospital, weighs in. “The PNDT people are right in saying that doctors have not taken up the responsibility, so they have been forced to implement… They say, ‘Why don’t doctors take the lead and institute internal controls so we don’t reveal the gender?’”
A member of the National Inspection and Monitoring Committee of the PCPNDT Act, Dr Sabu M. George, summed up the issue in a recent article in The Indian Express:
“The country will welcome incentives for girls. But the only immediate deterrence against continuous promotion of sex selection by unethical medical professionals and agents is the implementation of the law. The law was enacted because professionals did not follow medical ethics. And Gandhi’s endeavour to put the burden on women to stop sex selection is unforgivable – they are being punished for crimes that are being perpetrated by doctors. If the government does not have the will to regulate 55,000 clinics, how will it track 29 million pregnancies annually? In addition to the impossibility of this, it would undermine the abortion needs of women.”
Dr Kaul points out that “even in countries like the UK, where they tell the gender and it’s not a problem, for Asians they don’t,” clarifying that Asian is being used for members of the Indian, Bangladeshi and Pakistani communities.
“I used to work in an Asian-rich population [in Luton, England] and the NHS [National Health Service] hospitals have stopped telling the gender. They say it’s just fraught with problems… They realised the community is not using the information correctly, so it’s best to keep it away [from them].”