“It does not make any difference to my practice if I say no to provide an abortion, but it makes a great difference to my practice if I do an abortion and it turns out to be a female foetus.”  

This is what a doctor from Western Maharashtra was quoted as saying in a recently published study. The exploratory study, based on interviews with 19 gynaecologists in Western Maharashtra, found that getting a safe abortion by a registered gynaecologist has become difficult and, in some cases, is being outright denied to women.

Gynaecologists, who had between five to 20 years’ experience of working in districts with low sex ratios, admitted that they have been denying abortions to avoid the problems of paper work and dealing with “harassment” meted out by government health officers.

The study, "'If a woman has even one daughter, I refuse to perform the abortion': Sex determination and safe abortion in India" by Pritam Potdar, Alka Barua, Suchitra Dalvieemail and Anand Pawar, published this June in prestigious journal Reproductive Health Matters, was conducted by Pune-based NGO Samyak that works on the issues of gender, health and development. The study was done with an aim of documenting the knowledge and perspectives of private practitioners regarding the Medical Termination of Pregnancy Act, 1971, or MTP Act, and their experiences in dealing with health officials implementing the Pre-Conception & Pre-Natal Diagnostic Technique (Prevention and Misuse) Act, better known as the PCPNDT Act.

Abortion and sex-selection

It is estimated by the government that about 9% of the abortions in the country are for the purpose of sex-selection. After the 2011 Census showed that the sex ratio in Maharashtra dropped from 913 girls per 1000 boys in 2001 to 883 girls per 1000 boys in 2011, the government got cracking on ultrasound centres. In 2012, after the arrest of Dr Sudam Munde and his wife Dr Saraswati for performing a sex-selective abortion, the government decided to inspect abortion clinics too. In trying to boost the sex ratio, government officials started closely examining the second trimester pregnancies (post 12 weeks) after which the sex of the foetus can be determined.

In 2014, India's Ministry of Health and Family Welfare prepared a draft amendment to the law, which provided for abortion at up to 24 weeks and also brought in non-allopathic doctors, nurses and midwives to provide abortion under certain conditions. However, in Maharashtra, to avoid any kind of run-in with the government officials, many doctors in the state stopped conducting second trimester abortions. The only recourse left for women is to either continue the unwanted pregnancy or try unsafe means of abortion by non-allopathic doctors.

The government acknowledged the problem and a health ministry manual for abortion providers noted that women going in for unsafe abortions from uncertified providers “will contribute further to maternal morbidity and mortality and in fact, heighten the vulnerability of those very women (especially the poor, rural, of socially backward classes, adolescents etc.)”

In India, unsafe abortions account for about 3,500 women dying every year. Abortion complications are the third major cause of maternal death, after haemorrhage and sepsis.

However, doctors interviewed by the researchers admitted they were denying abortions, particularly second trimester ones, on various grounds. While some said record-keeping was cumbersome, some indicated that the different rules set up by local implementers of PCPNDT Act deter them, some said that they did not take referral cases that were not known to them, or cases where a woman had one or two daughters. If the aborted foetus turned out to be female, they could come under scrutiny, one gynaecologist said.

Dr Hitesh Bhatt, chairperson of the Ethics and Medico-legal committee, of the Federation of Obstetric and Gynaecological Societies of India, admitted that he had recently turned away a woman whose foetus was detected with congenital cardiac abnormalities. “I am within my rights to do so. The woman had two girls before this, and I didn’t want any headache. I told her to go to Gujarat and get it done. Nobody wants to take the risk,” he said. Foetal anomalies are a ground for second trimester abortion as per the MTP Act and many are detected only after the second trimester of pregnancy.

In some areas where the study was conducted, the professional medical organisations had advised members to avoid providing terminations, especially in second trimester. One doctor said that they discussed in their local association to send all cases of second trimester to the president who would inform respective medical officers, and give a “permission letter.”

Some of the doctors had arbitrarily increased charges of sonography (by Rs 100, said one doctor), “as compensation for the harassment they might face,” the study found.

Paperwork and harassment

The sector had by and large been unregulated till 2011. One doctor with 25 years’ practice complained about the three minutes he had to spend filling each form of about 40 patients each day “which could be invested in discussions with patients.”

Some doctors complained of negative experiences with the PCPNDT officials and felt that government officials do not have adequate knowledge about pregnancy. They complained that they come checking and “force them to show records” and “trouble them”. One doctor said that they are even blackmailed with sealing the machine or arrest or are asked bribes. All the respondents had had some negative experiences. One doctor had put up 11 closed-circuit television or CCTV cameras in his premise to ensure “there are no problems”, especially with wrong accusations.

And when they did try to help authorities, it had usually “backfired badly” resulting in an atmosphere of mistrust, fear and hostility, the study pointed out. “We give the authorities names of patients who ask for the sex of the foetus, but the authorities do not take cognisance. They say there is no proof,” said Dr Bhatt.

Doctors feel that the PCPNDT Act is against them, and used by the implementers to harass them. “If the form is not filled properly, or the patient’s signature or phone number is not taken, it is construed as sex determination. At least 80-90 % of the cases are based on forms not filled properly, but the headline in a newspaper says doctor caught doing sex-determination,” said Dr Bhatt. He said that in the recent past, the Federation of Obstetric and Gynaecological Societies of India has had meetings with all stakeholders including government authorities, and doctors in different parts of Maharashtra.

The gynaecologists seem aware of the implications of denial of services to women and the impact on their health. While admitting that denying abortion to unmarried girls could “create life-long problems”, five of the respondents said that they do not provide abortion services to unmarried girls “because they do not want to create problems for themselves.” Doctors said that they could either inform the police, or get permission from block medical officer or keep a copy of the identity proof such as a ration card before conducting abortion.

A larger problem

While being unanimous in their opposition to the practice of sex determination, some doctors in the study tried to “justify it from a cultural and religious perspective”, the study said. One doctor was quoted in the study as saying,
“But my personal opinion is that for a couple who have had three or four daughters, government should give them permission for sex selection for future pregnancies. Karan tyani achya samajala already 4 muli dilya aahet aani tyamule tyana mulga honyacha hakka aahe asa mala vatata (Because they have already given four daughters to our society so they have the right to wish for a boy).”

Samyak plans to do a larger study which includes not just private doctors, but government ones, women who seek abortion, non-governmental organisations and non-allopathic doctors who provide abortion (illegally). “Sex selective abortions should be seen from a larger perspective,” said Anand Pawar, executive director, Samyak. “A doctor should not be compelled to investigate if sex determination is done, before providing abortion. I feel that women should be at the centre of the discourse. We need to standardise abortion services.”

Recognising the inter-linkages between the two Acts, MTP and PCPNDT, at planning and implementation levels, the Ministry of Health and Family Welfare published guidelines – Ensuring Access to safe Abortion and Addressing Gender Biased Sex Selection – in February 2015 for health authorities and doctors to implement both Acts. The guidelines also recognise the faulty communication for prohibiting sex determination used by government authorities where words such as bhrun hatya or female foeticide, paap or sin, murder or killing are used creating create prejudice against abortion. Instead, words such as ling jaanch (sex determination) or ling chayan (sex selection) should be used.

Vinoj Manning, executive director, IPAS, a global nonprofit that works to increase women's ability to exercise their sexual and reproductive rights, and to reduce maternal mortality summed up the problem:
“The rules related to implementation of the Act changes from area to area, and implementer to implementer. On the other hand, doctors want zero regulations and have been systematically opposing it for over 20 years now. We have to address the problem both ways – from the implementers’ and the service providers’ point of view. We also need a redressal mechanism so that the system corrects itself, whenever there is a wrong-doing.”

Manning was also part of the panel of experts that worked on the guidelines related to abortions. But Dr Amar Jesani, independent researcher in bioethics and public health was aghast after reading the study:
“What kind of medical standards are these doctors upholding? Doctors do not like regulation and they want to discredit it. Doctors are becoming more conservative and religious. They do not perform abortion as it is not lucrative for them anymore. There is no doubt on reading the paper that the doctors are using the PCPNDT act as an excuse. It is also clear that there is a demand for sex determination from the community and so scrapping PCPNDT Act would provide more market to the doctors.”

Jesani added that the researchers did not validate the data given by the doctors, and that many doctors could be just repeating rumours. “Somebody with more sympathy for regulation of the sex determination technologies could have interpreted the data differently,” he pointed out.

Necessary paper-work?

The study also indicates that the paper work that PCPNDT Act mandates does serve a purpose.
“While Acts such as the PCPNDT Act should be implemented, so should the MTP Act, as well as laws against dowry, to prevent child marriage, to provide education and employment for girls and women, and ensure equal inheritance, paid maternity leave and so many others to ensure that all factors determining girls’ and women’s welfare are addressed in a holistic and comprehensive manner”

Activists working against sex selective abortions point out, the sex ratio in Maharashtra has increased after the government crackdown. A Lancet study published this month, shows that the number of girls in the state have slowly risen after the advent of PCPNDT Act, helping improve the sex ratio. Besides that, the reporting of abortions too has increased by over 31% since 2011.

“The doctors have to follow the paper work for PCPNDT, as per the law. Our work has been very good and is yielding results,” said Dr Sudhakar Kokane, Maharastra’s nodal officer for PCPNDT Act. He, however, added, that he has not heard a single complaint of a lady being denied abortions in the state. “As per the law, under certain conditions, a woman can get abortion. It is her right. Service to such ladies should not be denied,” he added.

The two sets of activists – the ones working on abortion rights and the ones against sex-selective abortions – are at loggerheads with each other, as is expressed in the paper. In an email, Sunita Bandewar, a researcher in Pune and the working editor for Indian Journal of Medical Ethics, said that regulatory authorities such as Medical Council of India and organisations such as Federation of Obstetric and Gynaecological Societies of India should lead the way, and even help in conducting sting operations on doctors conducting sex determination.

“I think the pressure on those indulging into illegal and malpractices needs to come from within their peer community… We need more doctors who value medical ethics and respect the noble profession alongside vigilant and well-informed masses at large,” Bandewar concluded.