Indian radiologists wrestle with law to prevent imaging-based sex-selective abortions

Sixteen years on from implementation of the Pre-Conception (PC) and Pre-Natal Diagnostic Techniques (PNDT) Act, burdensome bureaucracy penalizes many law-abiding radiologists in India. Furthermore, rather than preventing them, the act has driven up the price of illegal sex selection services. Meanwhile, registered ultrasound clinics face heavy fines for minor infringements.

Describing the act as “illogical on many occasions” in his address to the 63rd IRIA conference at Ahmedabad last month, Prof. Kishor Taori, referred to the “harrassment” of radiologists, and the act’s lack of desired results. Leading radiologists concur with his comments, citing anecdotal evidence of heavy-handed, even corrupt, officials cashing in on busy ultrasound clinics with large clinical workloads.

The 1994 act, along with its 2003 amendments, prohibits sex selection of a baby, before or after conception, and the regulation of prenatal diagnostic techniques for the purposes of detecting abnormalities, disorders, congenital malformations, or sex-linked disorders and provides for the prevention of their misuse for sex determination leading to what is termed female feticide in sex-selective abortions. (Follow these links for more on practicing radiology under this law and some obstetricians’ and radiologists’ perspective.)

Under the act, clinics and doctors using ultrasound must be registered with the Appropriate Authorities (AA) of the state, and display the registration certificate, as well as a notice in English and the local language stating that diagnostic techniques for sex selection are illegal and not carried out by doctors from the clinic. In addition, complete records, including Form F (which outlines reasons for the ultrasound and patient details), the referring doctor’s form, consent forms, and ultrasound images must be kept for two years. Monthly reports must be submitted to the AA, and proof of the reports’ receipt by the AA must be preserved by the clinic. Violations result in fines and up to five years in prison for more serious offences. Onsite checks are carried out by officials on a regular basis.

“The act itself is not illogical, it is the interpretation of the act,” said a senior radiologist who declined to be named. “The implementing agencies have wide-ranging powers to enter premises, check records, and seal [a facility]. Centers have been sealed just because of paperwork aberrations, which is not acceptable.”

Events such as machine seizure over missing signatures on forms have been occurring regularly over the last five years, and include the three-month confiscation of four machines from Deenanath Hospital in Pune, Maharashtra, with implications for the hospital’s outpatients and emergency throughput. In this case, the removal of the machines was due to three forms (out of 600) missing signatures, and was resolved through payment of a substantial fine.

“The act is an effective deterrent, and if found performing prenatal selection ultrasonography, the doctor can be and should be punished?if necessary, with criminal proceedings,” the senior radiologist said. “That, however, is not the issue. Because of the act, there is now a lot of compliance required with paperwork. Since hardly any radiologists have been ‘caught’ doing sex determination, the authorities are now catching radiologists on paperwork mistakes and using that as an excuse to institute proceedings against radiologists.”

Furthermore, radiologists cite corruption and vanity among enforcers and legal professionals, undermining the very goals of the act. The anecdotes are manifold and include lawyers offering to turn a blind eye to sex-selection services in return for payment, or conversely, promising innocent radiologists a hassle-free practice in return for remuneration. Underground sex-selection services now charge from five to 15 times the price of a standard obstetric scan, providing a lucrative business for doctors daring to contravene the law.

Other sources point to officials refusing to allow ultrasound machines to be used in demonstrations at workshop conferences because the request does not arrive in time for committee meetings, of enforcement monitors requiring busy doctors to write out statements by hand on the spot to prove their personal compliance with the act, and of the potential legal headache that routine cover may incur when a sonographer falls ill.

“We are required to name all users of any registered ultrasound machine, but if another colleague finishes scanning my patient to save time and save the clinic money, what happens then? Should the machine be seized and the clinic pay a fine?” asked another senior radiologist.

Compounding the situation further is fear persisting among the radiological community that openly adverse comments about the act will lead to real problems in their daily practice as authorities crack down on “troublemakers.”

While doctors and officials appear to be at loggerheads over application of the act, there is widespread agreement that legal and social measures are needed to address the potential population crisis through a multipronged approach.

In India the widespread undervaluing of women has led to an imbalance in the ratio of female births to male. Some studies estimate that over 10 million girls have “disappeared” from India’s population in the past two decades. Census data from 2001 show a national ratio of 933 females to 1000 males. According to these figures, the imbalance in the 0 to 6 age group in some states is more extreme, including Punjab with 793/1000, Haryana with 820, Himachal Pradesh with 897, and Gujarat with 878.

Given the stricter implementation of the act from 2000 onwards, and the first conviction under it in 2006, the current national ratio of women to men is slowly creeping up. Sting operations, in which NGOs (nongovernmental organizatons) use pregnant women with hidden cameras to catch illegal practitioners and pursue them in court, have improved ratios in certain areas. However, in others they remain skewed, especially for children aged 0 to 6. According to the Haryana census of 2001, some districts have even lower female birth figures: 770 in Kurukshetra, 789 in Kaithal, and 784 in Ambala.

Contrary to some perceptions, this is not a problem linked to poorer social classes, but is prevalent also in middle classes, with the lowest female/male birth ratios in communities where the dowry system affects marriage prospects. One advertisement claiming that a small amount of money spent now on a diagnostic test would save a couple a lot later on, has been banned. Conversely, one state-run prenatal health program promoting the importance of daughters offered couples completing the course US$20 on the birth of a girl and US$10 in the event of a son’s being born. Unsurprisingly, such programs have done little to change the mindset of a society that has for centuries favored men, and many female fetuses continue to be destroyed.

Although sensitive imaging techniques may depict gender as early as 13 to 16 weeks, pregnant women, whether they come in voluntarily or are forced by a husband or parents-in-law, will commonly approach an ultrasound clinic before the 20th week of pregnancy for diagnosis of fetal gender. Abortion, which has been legal since 1971 in India, becomes more problematic after this time. Doctors are prevented by Indian law from revealing the sex of an unborn baby, however established the pregnancy, in case the parents then use the information to seek a late abortion. In cases of sex-related genetic disorders, gender may be revealed, but for this to be allowed, an entire process has to be followed involving specific certified genetic counsellors and centers.

While some observers see radiologists as scapegoats being punished for a process involving many stakeholders, including the doctor performing the abortion, the parents of the female fetus, the extended family, and society at large imposing its views on the composition of an ideal family, for now, doctors seem to want the law to be improved, rather than overturned.

Rather than spending time chasing after small bureaucratic oversights by those carrying out legal scans, officials could invest time and effort in catching the real culprits still flouting the law. A New Delhi-based PNDT Act committee of radiologists is currently working on improvements to the wording of the act and a proposal for guidelines to be applied by those enforcing it. Specialists involved in obstetric imaging should be free to carry out their work unhampered, with lighter penalties, such as warnings, and a chance to rectify mistakes for less serious paperwork errors, according to one source.