Sex selection and abortion in IndiaBMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f1957 (Published 25 March 2013) Cite this as: BMJ 2013;346:f1957
Abortions for the purpose of sex selection in India have again caught the attention of Indian policy makers and the global press after the 2011 Indian Census showed a decline in the sex ratio. The number of girls per 1000 boys dropped from 927 in 2001 to 914 in 2011 for children aged 0-6 years.1 Most notable was Maharashtra state, which recorded a decline in the sex ratio from 913 in 2001 to 883 in 2011. Under an intense media spotlight, the state has set out to “save the girl child” under the tenets of the Pre-Conception and Pre-Natal Diagnostic Techniques (Prohibition of Sex Selection) Act. There have been waves of suspensions of doctors for violating this act.2 However, a parallel stream of ill informed directives may result in the victimisation of women seeking abortion.
The act3, passed in 1994 and amended before coming into effect in 2003, regulates prenatal diagnostic techniques in India and prohibits their misuse for sex determination. The act lays out minimum requirements for registration of clinics that use these techniques and the documentation that doctors must maintain. Designated authorities may conduct random “search and seize” operations at clinics and use decoys with hidden cameras or tape recorders to identify violations.
The act does, however, recognise its links with the Medical Termination of Pregnancy Act and reinforcement of its provisions. The Medical Termination of Pregnancy Act is a progressive piece of national legislation that ensures that the law will not hinder women choosing to terminate pregnancy. The core objective is to reduce anguish and health risks to women due to unintended pregnancies. The Prohibition of Sex Selection Act in no way infringes on the provisions of the Medical Termination of Pregnancy Act or permits state authorities to act in ways that may restrict a woman’s right to abortion.4
In light of this, the Maharashtra government’s recent spate of policy directives, aimed at curbing sex selection, seem to be misdirected. These directives include recommendations to reduce the abortion limit to 10 weeks5; introduction of a “silent observer” technology that relays ultrasound images from pregnant women to authorities to track potential sex selective abortions6; and the requirement that doctors take digital images of the fetus after abortion.7 Such policies are a blatant intrusion of women’s privacy and may drive them to seek unsafe methods of abortion.
Furthermore, policy directives seeking to restrict the availability of abortion pills have recently been proposed. In India a combination of mifepristone and misoprostol is approved for termination of pregnancy up to seven weeks.8 The state, however, seeks to ban retail sale of these pills or place them on schedule X,9 which requires rigorous record keeping of women who purchase the pills, with the potential to trace their whereabouts.10 A clampdown on manufacturers and retailers of abortion pills has led to the withdrawal of these pills from the market and an ensuing shortage.11 This has occurred despite World Health Organization recommendations to phase out surgery for first trimester abortions in favour of medical methods.12 The government also seeks to mandate a three visit schedule to the hospital for termination using abortion pills. This flies in the face of current guidelines that permit doctors to prescribe these pills at their clinic, provided women have access to a registered facility for abortion.9
Such measures clearly have little to do with preventing sex selection but do hinder provision of safe abortion services. By seeking to implement them the state ignores recommendations from gynaecologists and social scientists, as well as the law as framed in the Prohibition of Sex Selection Act and Medical Termination of Pregnancy Act. The Federation of Obstetric and Gynaecological Societies of India has repeatedly advocated for access to abortion pills and extension of abortion limits. The National Commission for Women has recently recommended extending termination up to 24 weeks, from the current 20 weeks.13 While the country looks towards liberalising abortion in the interests of the safety and health of women, regressive policies by the Maharashtra government to curb sex selection run the risk of criminalising abortion.
Evidence has consistently shown that liberal abortion laws coupled with government commitment lead to a decline in unsafe abortions and associated complications.14 In 2011, more than 620 000 abortions were reported in India. The real numbers may be well over six million, largely performed in non-registered institutions, by untrained people, and in unhygienic conditions.15 Unsafe abortions account for nearly 8% of all maternal deaths in India.16 As India tries to reduce maternal mortality as part of the millennium development goals, fostering women’s access to safe medical abortion is crucial.
With increasing availability of techniques such as preimplantation genetic diagnosis and blood tests to determine the sex of a baby,17 18 targeting abortion services would not solve the problem. Sex selection is common among the affluent and educated in India, as well as those of Indian descent who live abroad.19 What really needs to change is the fabric of the patriarchal Indian society that undervalues girls and women.
Cite this as: BMJ 2013;346:f1957
Competing interests: I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: None.
Provenance and peer review: Not commissioned; not externally peer reviewed.