"She would never have been born if her parents had not wanted a daughter." This copy went along with a small photograph of Indira Gandhi as a young girl. It was one of the prize-winning entries nearly two decades ago in the Ashok Jain Awards for Public Awareness Advertising. It was also a direct attack on the growing practice of female foeticide in India, driven by the then-new medical technology called amniocentesis. This added to the already rampant practice of female infanticide in some parts of the country and led to a sharp fall in the sex ratio biased against females.

The 2001 Census shows that the sex ratio is continuing to drop at an alarming rate all over the country though the degree might differ from one state to another. According to some estimates made by Population First, a non-government organisation that works on population and health issues in India, approximately five million female foetuses will be aborted every year over the next five years. Child sex ratio statistics in the 0-6 group has been showing a continuous decline over the last four decades, growing sharper since 1981.

The current all-India sex ratio in the 0-6 group is 927:1000, which is a dangerous sign of a demographic catastrophe on a nation-wide scale. This fall, from 976:1000 in 1961, is alarming because the country is registering an upward growth in many other areas. This underscores that economic prosperity and education have no bearing on the sex ratio, or, in other words, the traditional preference of sons over daughters. It also points to the fact that modern medical technology is being used for purposes that are at complete odds with the stated goals of healthcare.

Testing times

In India, amniocentesis was first used to detect abnormalities in the unborn foetus in 1975, at the All India Institute of Medical Sciences (AIIMS), New Delhi. As soon as news spread that these tests could also detect the sex of the foetus, doctors at AIIMS noticed that most of the 11,000 couples who volunteered for the test were interested only in knowing the sex of their unborn baby and had no interest about genetic abnormalities. Women, who already had two or more daughters, asked for abortion, legalised in 1972.

Using medical technology for sex determination is an extreme form of violence against women. The mindset of the society at large and the family in particular ensure that the woman, whose body is being subjected to a chain of needless medical explorations and techniques, has no say in the matter.

 •  A murderous arithmetic
 •  A cultural deficit

Today, the three chief pre-natal diagnostic tests that are being misused to determine the sex of a foetus are amniocentesis, Chronic Villi Biopsy (CVB) and ultrasonography. Amniocentesis is meant to be used in high-risk pregnancies, in women over 35 years. Amniocentesis is advised in the following cases: when the pregnant woman has a history of one abnormal child - mentally or physically challenged; when either parent has a congenital defect; when the couple falls within the 'high-risk' category of producing a defective child; when a previous child has been born with Down's Syndrome or neural tube defects; when parents have hereditary and metabolic disorders; to detect haemophilia, a rare blood disease; and when sex has to be determined for sex-linked hereditary diseases.

Amniocentesis tests can detect 1500 genetic abnormalities, thus helping in advising parents to decide whether they would like to have the child carried till full term or whether they would prefer to get it aborted.

Similarly, CVB is used to diagnose inherited diseases like thalassaemia, cystic fibrosis and muscular dystrophy. Ultrasonography is the most commonly used technique as it is non-invasive and can identify up to 50 per cent of abnormalities related to the central nervous system of the foetus. But sex determination has become its preferred application. This is despite the fact that using diagnostic techniques for sex-selection is discriminatory and violates the fundamental right to equality, not to mention the Pre-Natal Diagnostic Techniques (Regulation and Prevention of Misuse) Act - PC and PNDT Act of 1994.

The Act disallows the use of pre-natal diagnostic techniques for sex determination; it says that such techniques can be used only for detecting genetic or metabolic disorders, chromosomal abnormalities or certain congenital malformations or sex-linked disorders. The Act adds, "No person conducting prenatal diagnostic procedures shall communicate to the pregnant woman concerned or her relatives the sex of the foetus by words, signs on in any other manner."

The Parliament enacted the Act after the disturbing child sex ratios in the 1991 Census figures led to consistent campaigning on the issue by women's groups and other civil society groups across the country. The Act has been upheld by the Mumbai High Court in the case of Mr and Mrs Soni vs. Union of India and CEHAT, 2005. The judgement states: "The right to life or personal liberty cannot be expanded to mean that the right to personal liberty includes the personal liberty to determine the sex of the child which may come into existence. Right to bring into existence a life in future with a choice to determine the sex of that life cannot in itself be a right."

Child sex ratios across Indian districts (females per 1000 males) from Census 2001.

Loopholes in legislation

The mere enactment of the PNDT Act, however, does not seem to have been enough. For one, under the Act, the government can overrule the decisions of the body set up to monitor facilities, which is empowered to suspend or cancel the licenses of offending clinics or laboratories. The government can also exempt any facility from the Act. An ordinary citizen cannot directly move the courts, but must approach the monitoring body instead; this body can refuse to release any records if it's deemed that it's in public interest to keep them sealed.

The result of such partial regulation is that sex determination and selection facilities have been privatised and commercialised, and are mushrooming. Doctors indicated that despite bans, they would continue to communicate the sex of the foetus to parents who wanted to know, verbally rather in writing, and would hike the fees of the test to compensate for the legal risk. This is mentioned in the book Sex Selection Issues & Concerns: A Compilation of Writings by Qudsiya Contractor, Sumita Menon and Ravi Duggal.

After the 2001 census revealed a further fall in the child sex ratio, the government amended the Act to give it more teeth, and also to cover new pre-conception sex selection techniques, in response to directives of the Supreme Court in a Public Interest Litigation filed about this issue. Thus, the Pre-Natal Diagnostic Techniques (Regulation and Prevention of Misuse) 1994, as amended in 2003, came into effect in February 2003.

The amended Act, called the Pre-Conception and Pre-Natal Diagnostic Techniques (Prohibition of Sex Selection) Act, not only prohibits determination and disclosure of the sex of the foetus but also bans advertisements related to preconception and pre-natal determination of sex. All technologies of sex determination, including the new chromosome separation technique, fall under its ambit. The Act has also made it mandatory for ultrasonography units to prominently display a signboard that indicates that detection/revelation of the sex of the foetus is illegal.

The Act requires that all ultrasound scanning machines have to be registered with the "appropriate authority", who could be the ward health officer in large cities and district medical officers in districts, towns and rural areas. Manufacturers are required to furnish information about clinics and practitioners to whom they have sold ultrasound machinery. Between 2001 and March 2006, 28,422 facilities offering ultrasound tests were registered across the country. Three hundred and eighty four cases have currently been filed for various violations under the Act, such as communicating the sex of the foetus, non-maintenance of records and non-registration. The statistics, however, makes it clear that this is a sheer drop in the ocean, considering the massive number of facilities available in India among clinics and practitioners.

Besides, there are doctors in this country who seem to believe they are rendering a social service by participating in clandestine amniocentesis tests, followed by voluntary abortion, as they are saving the would-be mother from social and family torture! "Attitudes of medical practitioners reveal that they view sex determination tests as a 'humane' service they provide to couples not wishing any more daughters; as a regrettable but unavoidable result of the preference for sons in Indian society which they feel powerless to change," say S Sudha and S Irudaya Rajan in their research paper Intensifying Masculinity in Sex Ratios in India - New Evidence (1981-1991), supported by a grant from the United Nations Fund for Population Activities.

They add that the preference for male children in India is unchanged by mortality decline and socio-economic development. The increase in the number of boys as compared to girls - as evidenced in sex ratios at birth - in urban areas, which have higher literacy rates and better coverage of vital registration and health services, suggests that the trend is due to the spread of prenatal sex determination and selective abortion of female foetuses rather than female under-registration or infanticide. The trend coexists with the high female child mortality rate and the practice of female infanticide persisting in many parts of the country.

Killing fields

A 1995 investigation by Adithi, a non-government organisation working in rural Bihar state, revealed that female infanticide, foeticide, and excess female child mortality due to selective neglect were widespread in the eight districts it studied. As reported in the paper Intensifying Masculinity in Sex Ratios in India' infanticide was carried out by dais (traditional birth attendants), who were coerced into doing this by the senior male kin of the woman giving birth, over-riding the protests of the women in the family. Fear of reprisals, poverty, and lack of alternative occupation made the dais comply. Other medical practitioners such as compounders and doctors also carried out infanticide when approached by the family members of a newly born girl child. There was no difficulty in committing infanticide, because the birth and death followed quickly upon each other, with no certificate recorded for either event. Unscrupulous medical practitioners also conducted abortion of female foetuses, especially after techniques like sonography became widespread.

There are doctors in this country who seem to believe they are rendering a social service by participating in clandestine amniocentesis tests, followed by voluntary abortion, as they are saving the would-be mother from social and family torture!

 •  A murderous arithmetic
 •  A cultural deficit

The report describes how the traditional skill of dais in identifying the sex of a foetus in the seventh or eighth month of pregnancy is used to avert the birth of a daughter. Going by a count of 68,000 dais in seven contiguous and culturally similar districts of Bihar, and that each dai killed about two infants a month (according to the interviews), Adithi estimates that the number of female infanticides each year in these districts could be as many as 16,32,000. In other parts of the country, where sex determination tests are available, using these - to be followed by abortion if it's a girl - seems to be preferred to abandoning baby girls or female infanticide.

An extreme form of violence

Using medical technology for sex determination is an extreme form of violence against women. The mindset of the society at large and the family in particular ensure that the woman, whose body is being subjected to a chain of needless medical explorations and techniques, has no say in the matter. It is her body that is being violated without her express consent. In the rare instance of her permission being sought, she is morally and psychologically coerced into acquiescence. She agrees because she is horrified of being subjected to torture if she delivers a girl child. Coupled with this horror is the panic that may be, if she does not undergo the test, the girl will be killed after she is born anyway.

Puloma Shah, who worked in a US cytogenetics laboratory for over a decade, points to the dangers lurking behind sex determination tests, especially in the case of amniocentesis. It consists of the insertion of a long, aseptic needle into the amniotic sac through the mother's abdomen and withdrawal of 15 to 29 cc of amniotic fluid from it for chromosomal analysis. The test is usually done after 14-16 weeks of pregnancy. According to RP Ravindra of the pharmacology department of the SNDT University in Mumbai, the test is performed at a time when it's reasonable to withdraw fluid sufficient to contain the number of cells without damaging either the placenta or the foetus.

However, if abortion is chosen after this stage, it can be dangerous. Shah says that if clinics do not use ultrasonography to locate the position of placenta and foetus during amniocentesis, it might result in spontaneous abortion if the placenta and the foetus are damaged. Besides, as many Indian women are anaemic, the test-abortion-test cycle is equivalent to committing physical violence on the woman, she adds.

It's because of these practices that the sex ratio is so skewed in several parts of the country. In Dang district on the Gujarat-Rajasthan border, eight brothers of the same family are married to one woman because it is extremely difficult to find a wife in the region. In 1997, when Devra village in Jaisalmer district in Rajasthan received a baraat, it was a rare event - it was the first time a baraat had come to the village in 110 years. In some villages in Madhya Pradesh, no marriage has taken place for years as there are no girls. The boys marry girls from Bihar, reportedly after 'buying' them. Despite these horror stories, the fact that female foeticide and sex determination tests continue unabated is an indication that we still haven't grasped the enormity of this tragedy.