Sex Determination Test -Sex Selective Abcention

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Title
Sex Determination Test -Sex Selective Abcention
extracted text
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RF_WH_8_PART_2_SUDHA

I INVESTIGATION

Scanning for death
In a region in Tamil Nadu where female infanticide is endemic, increasing instances of foeticide
employing modern tools of medical technology raise a range of questions.
ASHA KRISHNAKUMAR
in Usilampatti

“natural”. Women waiting outside a scan over a hundred scan centres.
All the scan centres in Usilampatti taluk
centre in Thirumangalam village spoke of
one instance in Pudipuram village in operate illegally - they have not obtained cerwhich a baby girl had died within five tificates of registration from the appropriate
days of birth: she had been starved to authority as required under law. For Rs. 150,
death. In Kumuli village, a 15-day-old girl the centres scan foetuses to determine the sex
had been buried alive. And in Sadachipatti - in blatant violation of the law and medical
village, a baby girl was left in front of a ethics - and discreedy disclose the one bit of
table fan running at full speed. She died information that will decide wnether or not
' the foetus will be allowed to live: its gender.
within a few hours.
Increasingly, female foeticide is being
widely practised in many villages in Madurai T? MERGING from the scanning room,
district and the neighbouring Salem district. JL-/Rajathi is crying uncontrollably: it is a girl,
Certain that she will not be abue to face her
Acft-ances in medical technology are being
’
misused to aid the practice: in recent years husband and mother-in-law, she decides to
there has been a proliferation in the number go back to her parents’ village and abort the
of scan centres even in remote villages that foetus. Some of the women in the village will
otherwise have only the most rudimentary help hen their methods will be crude and will
public health facilities. There are 13 scan cen- probably put Rajathi’s own life ar risk, but her
tres in and around Usilampatti taluk - three mind, condirioned by traditional social valin the town, five in Theni, two at ues that look upon female children as a “bur­
Thirumangalam, and one each at Andipatti, den” on the family, is made.
Vathalagundu and Kallupatti. In Madurai
Amaravathi too has discovered that
city, 40 km from Usilampatti town, there are she bears a girl child, but uniike Rajathi,

A T noon on an unusually hot
-/^November day, the village street is
deserted except for the occasional cyclist.
In one particular building, however, there
is a throng of people, most of them
women, their numbers so large that they
almost spill out on to the street. Here is
an ultrasound scan centre which offers
pre-natal diagnostic facilities, ostensibly
to monitor the health of the foetus but, in
many cases, to determine its sex for a dead­
ly purpose.
Over by a corner, quite oblivious to
the presence of others, Sarasamma, who
has just had her foetus scanned, and her
mother-in-law are arguing loudly, but in
a chilling matter-of-fact tone, about when
to snuff out a life: should the female foe­
tus that Sarasamma bears be killed in the
womb or should they wait a few months
for the baby to be born and then starve
her to death?
l<
This is Usilampatti taluk in
I
Madurai district in southern
10
Tamil Nadu, where girls are born
to die - or, as is increasingly the
case, are denied even the chance
to be born. Female infanticide is
known to be endemic in the area
but the State Government claims
that such instances have declined
following the introduction in
1992 of a number of schemes to
address this ‘sociological’ crime.
However, the situation is still
serious: despite awareness cam­
paigns
organised by the
Government and the fear of the
law following the arrest in 1996
of Karupayee on charges of
killing her girl child, female
infanticide continues to be prac­
tised here widely.
As I discovered during a visit
to some villages in Usilampatti
taluk in mid-November, many
.
mothers seem to starve or suffo- L——
cate their female children to A scan centre in Usilampatti. Such centres have proliferated in villages that otherwise have
death, making the deaths appea • the most rudimentary public health facilities.
UJ

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FRONTLINE, DECEMBER 18. 1998
■

109

she contemplates abortion with noncha- of Indic Gazette Notificationi states: Tamil Nadu - Salem (849), Dharmapuri
n
“Every cinic shall prominently display on (905) and Madurai (918) - are revealing,
lance. “Of course, I will abort the foetus,
itsrpremiss
a notice in English and in the Salem district, in fact, recorded the lowshe says. “Rajamma, who retired as a nurse i._
...
in the Usilampatti Government Hospital, local languige or languages for the infor- est juvenile sex ratio in the country. The
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"ill
W1I perform the abortion, as she has done mation ome public, to the effect that dis- three districts accounted for 41 out of 46
for many others, charging less than what closure or the sex of the foetus is blocks in Tamil Nadu which had a rural
juvenile sex ratio of 900 or less. The State
prohibited under law.”
the private hospitals charge.”
Under Section 10(1) of the Gazette Government’s claim that instances of
In
Ayankoilpatti,
Ichampatti,
Kalyanipatti, Thummakundu, Lingan- Notificatun, before conducting any pre- female infanticide have declined in
and natal diapostic procedure, scan centres Usilampatti taluk after the initiation of a
ayakanpatti,
Pudhipuram
Pothampatti villages, women who are are require! to obtain from the pregnant number of schemes in 1992 is not borne
even seven months into their pregnancy woman a vritten consent “as specified in out by data compiled for 1995 by prima­
have gone in for abortions after a scan Form G. in a language the pregnant ry health centres in the State. Female
revealed the sex of the foetus. In Vadipatti woman muerstands”. By signing Form infant mortality rate (defined as mortali­
village, a 25-year-old woman died while G, the premant woman “undertakes not ty in the first year per 1,000 females
to termintre the pregnancy” if the pre­ bom) in Dharmapuri district was 100.1;
trying to abort her seven-month foetus.
natal tests disclose no foetal deformity or in Madurai it was 70; and in Salem it was
C EX-DETERMINATION tests and, disorder, me is further required to state 85.4. The figure in respect of the whole
Oi'consequently, female foeticide became that she ‘ inderstands that the sex (of the of Tamil Nadu was 44.3. Specifically, the
in India
the 1970s. foetus wil not be disclosed” to her. earlv neo-natal female mortality, rate (that
.
known in India
in thein 1970s.
Owinrro poor implementation ofthe is, death within six days of birth) iin
iocentesis, an invasive sex-determiDharmapuri
district was 76; in Madurai
’
nauon test, was prevelent in the 1970s and Act, hovever, sex-determination tests T
the early 1980s in Delhi and spread rapid- continue n be carried out with impuni- it was 43.4; and in Salem it was 60.4. The
ly to other parts of the country, particu- ty. And sei-specific abortions, assisted in State average was 24.
larly to Maharashtra (Frontline, July 9-22, many insunces by doctors and paramed1988). According to some independent ical persomel, continue to be performed, T SET out from Madurai for Usilampatti
estimates, of the 8,000 abortions done in sometime:at great risk to the woman. The JL taluk along with members of the Society
Maharashtra in 1987, 7,999 involved long-terrr. sociological consequences of for Integrated Rural Development
female foetuses. With public outrage these uniavrul, unethical acts are serious (SIRD), a voluntary organisation which
has been active in the area for 20 years and
against amniocentesis mounting, the in the exmme.
which in 1986 first highlighted the
Maharashtra Government enacted a law
A CCCRDING to Census of India instances of female infanticide in the
on May 10, 1988 to regulate pre-natal
diagnostic centres. None of the other .xldata fir 1991, the sex ratio (defined region. They are: SIRD field director M.
States or the Central Government, how­ as the nunner offemales per 1,000 males) Vasu and field officers C. Maunam, P.
v: Pavalam and C. Jayamani. The economy
ever, did so. It was only in 1994 that the for the uvenile population (0-6 age
Pre-Natal Diagnostics (Regulation and group) ofTamil............
Nadui was f948, against of the region is primarily agrarian, and as
Prevention of Misuse) Act was put in the natiomi average of945. However, the we approached Usilampatti town, the
figures ir respect of three districts in landscape turned from fertile to dry. The
place.
disparity in living condi­
Under the Act, pre­
tions in the different areas
natal diagnostic scans are
was striking. In the fertile
permitted solely to detect
areas, the houses were regu­
“tic abnormahties at
lar constructions and had
. pre-natal stage. The Act
television sets, refrigerators,
forbids sex-determination
mixies, grinders and sofa
tests. Chapter III Section
sets. In contrast, in the dry
6(b) of the Act states: “No
areas, the houses were
person shall conduct... any
thatched structures and had
pre-natal diagnostic tech­
few belongings.
niques ... for the purpose of
We were to meet a few
determining the sex of a
SIRD members; since most
foetus.” Further, Chapter
DEVffKI
of them were apprehensive
III Section 5(2) of the Act
... SCANS
x.‘.
___-»
about talking to us in their
states: “No person con­
villages, we had arranged to
ducting pre-natal diagnos­
meet them at the SIRD
tic
procedures
shall
office at Periyasemmetcommunicate ... the sex of
tupatti, two km from
the foetus by words, signs
Usilampatti town. By the
or in any other manner.”
J®®
time we reached the village,
The Tamil Nadu
28 women from nine sur­
Government framed the
rounding villages had gath­
rules and gazetted the Act
*
ered. Initially most of them
in January 1996. Section
claimed that they had never
17(1) of the Government A scan centre In Madura.

I

110

FRONTLINE, DECEMBER 18, 1998

gold, a TV set, sofa, cot, cupboard,
mixie and grinder. How can I afford
all this?”
According to Maunam, the prac­
tice of giving huge dowries began in
the early 1960s. With the opening of
the Vaigai dam, there was a boom in
the agricultural economy in the
region; some people were better
equipped to benefit from it, and
income
disparities
widened.
Consanguineous marriages gave way
to a system whereby the rich offered
huge dowries in order to get “good
bridegrooms” from outside the fami­
ly. The “offers” were soon replaced by
“demands”, which over time became
increasingly unrealisable for all but the
most affluent.
Gender disparity manifests itself
in several other ways in a patriarchal
society and contributes to the shaping
of a mindset that perceives girl chil­
dren as a “burden”.
In 1992, the State Government
acknowledged for the first time the
seriousness of the problem of female
infanticide. It introduced several
schemes,
including one under which
“Cradle babies” at Usilampatti In 1994. The “cradle baby scheme” fizzled out.
parents could abandon “unwanted”
committed female infanticide or foeti­ houses with the help of hospital nurses. In girl babies in cradles kept in noon meal
cide. But even as they narrated instances Vadipani village, a six-month foetus was centres, primary health centres and
in “other families”, some of them broke aboned thus in October. Early in orphanages; the babies would then be
down and confessed to having committed November, a five-month foetus was said
‘
brought up in State-run orphanages.
similar crimes.
to have been aboned in Iyyamkoilpatti by About 50 babies were thus found abanSanthosam from Sadachipatti village a retired government hospital nurse.
doned in Usilampatti. But the scheme fizsaid: “Female infanticide still goes on, but
A few others go to
to Madurai
Madurai and
and zled out because many babies that were
after the arrest of Karupayee the methods undergo abonions at one of the dozens “adopted” by the State died. According to
used are different.”
of private hospitals there.
data compiled by the Social Welfare
Rasamma of Kalyanipatti village
Department, 133 babies were found
explained: “We no longer kill the girl baby CEVERAL sociological factors influ- abandoned in cradles in Usilampani and
with the poisonous sap of the oleander O ence the preference for male children Salem between 1992 and 1996. Of these
plant as traces of the poison can be detect­ that is at the root of female infanticide and 70 died.
ed (in post-mortem examinations). We female foeticide. The heart-rending tale of
Another scheme, under which the
make the death appear natural. For Thedaselvam exemplifies some of them. State Government was to invest Rs.2,000
instance, we starve the baby to death or Frail and anaemic, she had tried to abort in the name ofevery girl child born in poor
asph}7xiate it... Women who cannot afford her five-month-old foetus but her hus
hus-­ households, was not implemented until
a scan or an abortion prefer these meth­ band, who had lost both his legs in an acci­ 1997.
ods.” Poomani of Ichampatti village said dent, had prevented her. His overriding
that in some instances, the baby was concern was that ifshe died owing to com­
A CCORDING to the women of
buried alive within the compound of the plications arising from an improper abor­ TkUsilampatti, following the arrest of
house.
tion, there would be no one to look after Karupayee, fear of the law prompted a
Among those who go in for sex­ him and their eight-year-old son and six- decline in the reported instances of female
determination scans and learn that the sex year-old daughter: the family survives on infanticide. It was then that scan centres
°f the foetus is female, not everyone opts the Rs. 15 a day that Thedaselvam earns mushroomed in the region, offering the
for or can afford an abortion in a hospi- as a farm labourer. But Thedaselvam facility for early detection of the sex of the
td. Annakodi recalled that in Pothanpatri asked tearfully, “What will I do if this too foetus.
Ullage a woman tried to abort her female is a girl? The expenditure we incur on a
According to T.T. Guhan, Deputy
foetus with an oleander stem. The abor- girl all through her life is enormous (there Director (Administration), Directorate of
don was incomplete and the woman are she occasions on which ceremonies are Medical and Rural Health Services,
developed high fever and fits. She was to be performed for a girl). For the mar- Chennai, none of the scan centres in
Wished to hospital but died a day later. riage, which entails a huge expenditure, Usilampatti is registered with the
Some women undergo abortions in their we have to give at least 10 sovereigns of Directorate, which is the Appropriate
frontline, December is. 199s

1

111

Authorin’ for the imple­
A third woman doctor, who offers
Sex-f specific abor­ to an abortion regardless
mentation of the Act.
of the accuracy of the sex scan facilities in Usilampatti town, said
tions,
assisted
in
The Advisory Commdetermination.
that she performed four or five abortions
many instances
inee set up to aid and
a day. Asked about the ethics of sex-speadvise the Appropriate
A WOMAN doctor cific abortions, she said: “I offer the poor
by doctors and
Authorin'
met
on
-Zjcwho has been prac­ a place where the abortion can be conparamedical per­
November 3; it decided
tising in Usilampatti ducted without health risks to the mothsonnel, continue
to send out notices to the
town for 10) years said er. Otherwise, these poor people will be
scan centres that have
that she handled about 25 at the mercy of quacks.”
to be performed,
not been registered with
abonion cases a month She claimed that there was no need
sometimes
at
the
Appropriate
most of them incomplete for scan centres to be registered as scangreat risk to the
Authorin’.
abonions,
pre-marital ning was an out-patient procedure. She
Most of the scan
woman. The long­ pregnancies and sex- admitted that she disclosed the sex of the
centres in Usilampatti
term sociological selective abortions - after foetus orally or symbolically or through
have been established by
securing in each case the her assistants. The number of requests for
consequences of consent of the parents or scans had increased in the last two or three
doctors who appear to
have little hesitation in
the husband. Her clinic years, she noted,
these unlawful,
disclosing the sex of the
does not have scanning
A private scan centre which was
unethical
acts
are
foetus - which they do
facilities but she refers her opened in 1996 in Usilampatti town is
serious in the
either orally or by scrib­
cases to centres in run by some doctors. One of them, whom
bling ‘xx’ (referring to
Madurai and Usilampatti we met at the centre, insisted that there
extreme.
female chromosome
town. Even as we were was no need for the scan centre to be reg­
pattern) on a piece of paper. Shockingly, talking to her in her clinic, a man repre- istered or for the pregnant woman’s condoctors who run the scan centres and senting a scan centre in Usilampatti sent to be obtained for a scan. The centre,
those who perform abortions seemed to brought her share of Rs. 25 for every he said, was started as there was a demand
be unaware of the Act and the fact that patient she referred to the centre.
for it in Usilampatti. He said that 75 scans
their actions in performing sex-determi­
She initially claimed that the sex ofthe a month were performed at the centre; he
nation tests and disclosing the sex of the foetus was never disclosed, but on repeat- conceded that the sex of the foetus was
foetus constitute a punishable violation of ed questioning admitted that the infor- disclosed orally to some women.
the law. Chapter II Section 3(3) of the Act mation was communicated orally to some
Another scan centre in Arasanedi, set
states: “No medical geneticist, gynaecol- women.
up a few months ago, performs at least 15
ogist, paediatrician, registered medical
According to her, most of the scans a day. It is patronised by many peopractitioner or any other person shall... aid demands for abortion came from people pie from Usilampatti taluk,
in conducting... any pre-natal diagnostic belonging to the Kallar community, withUnder
Under the
the Act,
Act, scan
scan centres are
techniques at a place other than a place out class distinctions. She insisted that she required to maintain records of patients
registered under this Act.”
performed sex-specific abonions only for for two years. At a scan centre in
the poor, sometimes even six months into Usilampatti it was claimed that records are
A N ultrasound scan can help deter- the pregnancy.
maintained for one month and then
Tkmine the sex of the foetus from
Asked if
if she did not consider sex- destroyed. The doctor at the scan centre
berween 16 and 20 weeks of pregnancy selective abonions illegal and unethical, of course refused a request to let us look
depending on the parameters of the she replied: “There is a (demand) for abor­ at the records in order to verify the broad
equipment. For instance, with the kinds tions, so I do it.” She added that some nature of the entries.
equipment generally available in nurses also performed abonions in their
.amparti, which have relatively low- houses.
TTAILURE to implement the Act has led
resolution monitors and do not have
According to another woman doctor, JT to the unregulated mushrooming of
trans-vaginal attachments, the sex can be private clinics performed three or four scan centres and the misuse of pre-natal
ascenained only by around the 20th week abonions a day, against the 15-20 a diagnostic techniques to determine the
of pregnancy. With the aid of equipment month performed at government hospi­ sex of foetuses; these in turn have led to
available in some scan centres in Madurai tals. The procedure in private clinics was increasing instances of female foeticide, in
it is possible to ascenain the sex in the 16th hassle-free and the patient would be dis- some cases at great peril to the lives of the
week of pregnancy. But in Usilampatti, charged a few hours after the procedure, pregnant women.
many doctors seem to resort to medical Before a scan was done, no forms needed
This grim situation raises larger ques­
termination of pregnancy for their to be filled in and the patient’s consent tions relating to basic socio-economic
patients even between 12 and 15 weeks of was not secured because it was only an out- circumstances, pressures and ‘compulpregnancy’.
patient procedure, she said. This doctor sions’, societal values and mental attiThere is also an incidental question too conceded that the sex ofthe foetus was tudestowards the girl-child, the failure
here ofthe level ofreliability of ultrasound disclosed to some patients. According to of the law enforcement system to imple'
scanning, that too at a fairly early stage of her, in several instances, the mothers had ment relevant legislation, and ethical
pregnancy, in foetal sex determination. abandoned girl babies at the hospital and issues concerning the medical profession.
According to a doctor in Usilampatti, the left within hours of the delivery; such ■
margin of error in the case of sex deter­ babies were handed over to the receiving
mination is small. A signal from the scan- centres run by the Indian Council for (The names ofsome persons referred to in the story
have been changed at their request.)
ning professionals almost invariably leads Child Welfare.
112

FRONTLINE, DECEMBER 18- 1998

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ETHICAL PRIVATE PRACTICE IN OBSTETRICS
Dr. Evita Fernandez
Fernandez Maternity Hospital Pvt. Ltd
Bogulkunta, Hyderabad 500 001.

s private practitioners we have the privilege and responsibility of setting standards for
U lourselves in teuns of the quality of service we offer our patients. Having been in the
fortunate position of inheriting a maternity practice where I look after the third
generation T bn''e

had to struggle against many odds. However, over the last decade

my main concern has been the building up of a team, keeping abreast of new technologies to

provide patients with the medical care, and following norms which we hoped and believed
were ethical in practice.
Every time a fresh postgraduate joins the team, we spend the first three months helping her
to learn (sometimes unlearn) communication skills, encouraging her to have a holistic

approach to the patient and to be honest in her work.

I am very often shocked and dismayed at the ready and easy resort to termination of

pregnancy as an answer /solution to a problem. I am angered when I see prescriptions and
a long list of investigations written in a flippant manner with no regard or concern for the

economic status of the patient. I am saddened to see the lack of respect and privacy given
to a patient during a clinical examination.

I fail to understand why we doctors do not inform a patient about ail the options available

enabling her to make an informed decision regarding the management of her clinical

problem.

Why do we link intelligence with economic status?

Why do we treat the

“illiterate” or "semi-literate” women with disdain and offer them no choice? We decide for

them. Is this ethical
As an obstetrician I am concerned about the consequences of medical technology. With

pre-implaniation diagnosis now being available - though at a prohibitive cost - will we
further increase what will now be termed '“fetal embryocide’}? Where will we draw the line?
Who will decide whether the embryo needs to be retained or flushed away because it is a

female?

I

Thanks to assisted reproductive technology, the incidence of multiple pregnancy (twins,

triplets, quadruplets) has increased. Embryo reduction seems to be a ready solution. How or rather who - does one decide which embryo to destroy? Is a mother given the choice to

refuse? I have had to counsel mothers who are burdened with guilt following such a
procedure, especially when the very embryo she tried to save is lost in a miscarriage or in a

preterm birth.

During a routine scan done at 20 - 22 weeks gestation, we still refuse to reveal the sex of
the fetus in our hospital.

The majority of our patients are comfortable when the scan

images are explained to them and they can see that their “baby” is apparently normal. Once
this is dong they settle down to accepting the “suspense” of not knowing the sex of the

baby. I believe this is where our attitude asjioctors/sonologists is important. Many of us
do not have the time to explain, nor are we interested in “educating” patient.

The Andhra Pradesh government has recognised the need to “welcome” a girl child. A
new scheme has been announced whereby every newbornjaby girl will bC-gLyen Rs^5000/-

to open a savings account, with the hope that she will be given an equal opportunity in life.
Whether the scheme will become a reality is questionable (although newspapers report that
a certain amount has already been disbursed), but it is a sign of hope.

Our hospital celebrated its golden jubilee this year. Being a Catholic institution we do not
encounter many patients who ask for a termination and so my experience with “female
feticde” is virtually nil.

I have had, however, to counseLpatients who experience guilt

following such procedures. Often the pregnant mother has been forced to undergo the
termination and has not been given a chance/choice to refuse. I firmly believe that no (J

mother wishes to remove a healthy child, be it a boy or a girl.

Why are we churning out doctors who are afraid to pause, think and reflect? Who are j
afraid to listen to the stirrings of their conscience and so do not ask soul-searching
questions? Ethics is essentially an invitation to each one of us to be fully human. Do we /

have the courage to respond?

71

Sec. 1]

HIE GAZE? lb OF INDIA
15 EXTRAORDINARY

34. Every rule and every regulation made under this Act shall be laid,
as soon as may be after ii is made, before each House of Parliament,
while it is in session, for a total period of* thirty days which may be com­
prised in one session or in two or more successive sessions, and if, before
die expiry of the session immediately following (he session or the succes­
sive sessions aforesaid, both Houses agree in making any modification in
the rule or regulation or both Houses agree that the rule or regulation
should not be made, tne rule or regulation shall thereafter have effect only
in such modified form or be of no effect, as the case may be; so, how­
ever, that any such modification or annulment shall be without prejudice
to the validity of anything previously done under that rule or regulation.

Rules and
regula­
tions to
be laid
beforo

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Parlia­
ment.

K. L. MO.HANPURIA,
Secy, to the Govt, of India.

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PRINTED BY THE MANAGER, GOVERNMENT OF INDIA PRESS, MINK) ROAD, NEW DELHI
*ND PUBLISHED BY THE CONTROLLER OF PUBLICATIONS, DELHI, 19^4,

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A sound practiceo 9
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was traumatised to find that the parents wanted
to wash their hands of the malformed baby and
had the temerity to tell doctors at the nursing
npHERE has been such a mushrooming of ulhome where it was born that they should keep
JL trasound equipment that "you will find an
the baby and do whatever they wanted with it.
ultrasound machine even in a village which has
Dr. Suresh recounts another problem con­
a road over which only a bullock cart can go,
nected with the Imaging technology, when It
and electricity to run the machine and nothing
comes to minor birth defects in the foetus which
else", says Dr. S. Suresh, director of the Foetal
are absolutely compatible with life and which
Care Research Foundation and a pioneer in the
can be easily set right after the baby is delivered.
practice of ultra sonography.
Says Dr. Indirani, "Even if we pick up a
"But, unfortunately, the medical fraternity is
clubbed foot or a cleft lip or missing fingers, and !
not able to bring out the full benefit from this
tell the parents this, the next question we get is: 1
‘Can we terminate the pregnancy safely?’ The
problem Is that the understanding of birth de- ;
fects even among doctors/obstetricians is not
total. We can make the diagnosis, but what fol-, ; |
imaging technology to detect malfunctions in
lows that is important. A special effort is neces- I
foetuses, counsel patients and guide them on
sary to ensure, that the implications of the *
how to avoid a recurrence of this abnormality in
diagnosis are explained to the parents and they
the next pregnancy," he adds.
are told that these minor defects can be set
right, mostly through plastic surgery, after the
baby is born." Another common problem they
encounter when they diagnose an abnormality,
however small, is that the husband immediately
turns around and says: "But how is that pos­
sible? There are no defective genes In our fam­
*
ily." As usual, anything to do with a deficiency
in the procreation process has to be passed on to
the wife and her family.
High expectations from this technology arc
also daunting. A recent case, which startled the
entire profession, was that of a baby whose fore­
arm was missing: the case was taken to the
consumer court, which directed the sonologist
to pay a substantial compensation.
Dr. Suresh says such cases have two implica­
kv*:
tions. One, sonography does not have all the
answers and depending on the position of the
Doctors S. Suresh and Indirani Suresh... pioneering work in the area of ultrasonography and foetal care, foetus, the period of pregnancy and when the
ultrasound is done, a diagnosis could be missed.
they come across infants with birth disorders.
What is most disturbing about this imaging
Two. such cases could have a negative fallout
With the available information, we can make a
technology is its blatant misuse in sex determi­
■ and lead to the practice of defensive medicine.
diagnosis, do autopsy studies of the baby, coun­ "To protect myself from any such litigation I
nation tests. About a year ago. this columnist
sel the parents and help them go through the
was shocked to find the proliferation of ultra­
could end up causing unnecessary anxiety to
next pregnancy by optimal use of the ultra­
the parents with vague answers like: ‘Well, I’m
sound machines in the smallest of towns In Sa­
sound and assure them that the baby is nor­
lem and Dharmapuri, the Tamil Nadu districts
not sure... it looks alright but I can’t say with
mal,” says Dr. Suresh.
certainty.’ Or I could make 10 different diag­
infamous for female infanticide.
He says the response to the registry has been noses which will confuse the.patient: It could be
Dr. Suresh admits that this is the most un­
quite good, and the effort initiated in Coimba­ this, or that or something else."
fortunate facet of medical advances which is yet
tore, in particularly, had paid good dividend.
But right now, the main objective before the
to be used optimally in the country to help
"Our Trust Is a purely voluntary, non-profit doctor couple is to standardise the practice of
mothers have children without’ abnormalities.
venture and the moment a doctor contacts us sonography. "We need to standardise ultra­
As in all countries, about 2.4 per cent of preg­
with a problem and wants our help, we arc most sound procedures and evolve standards of prac­
nancies have an abnormal component. "But,
tice. We have discussed this with the Indian
unfortunately, this particular group of people willing to do so," he adds.
According to Dr. Indirani. one problem in di- Federation of Ultra Sound (which has 2.000
with abnormal babies has not been looked after
at all. When they get abnormal babies, the fam­ agnosing foetal abnormalities is that while mcmbers) artd we are planning to bring out
cotrc Dr.
Hr Suresh.
Ciirnctl
P
ily blames it on fate and hopes for the best the some defects can be ruled out at 14-15 weeks of standardised guidelines,"19 says
in others it takes up to 25-28 weeks
next time. Rarely are records of the first preg- pregnancy,
. _
Dr. Suresh adds that a trickier issue to take up
. _ ? one. "Sometimes only at this period with the Federation pertains to using sonog­
nancy available, as the parents keep going from to diagnose
one doctor to another, saying that the previous can we find that the foetal head is very small raphy for sex determination tests. This is much
(medically known as microcephaly) and the ab­ more difficult to enforce at a collective level. "As
doctor was not lucky, so try another."
normality will be incompatible with normal life far as we are concerned, there are two things we
In all this, what gets Ignored is the possibility
will not do: Conduct sex determination tests and
of counselling patients based on the ultrasonog­ as the baby will be severely retarded."
Even when an abnormality is discovered rath­ give cuts (kickbacks to the referring doctors)."
raphy evidence so that the birth of a severely
er late — after 30 weeks of .pregnancy
r
- — there
Says Dr. Suresh: "Our Instructions to our re­
malformed child can be avoided.
The other aspect of the issue is that for a arc ttechniques to stop the foetal heart and tlien ception desk are to throw out anybody who
J--.1
n„. .
...or, . comes with an inquiry of a sex-determination
mother who has had an abnormal child, the deliver a dead baby. But the problem is when it
anxiety factor during the next pregnancy would is not possible to stop the foetal heart. Accord­ test. I don’t even allow them to meet me so that I
be very high and she needs to be assured that ing to sonographisLs. on occasion. Jive babies could counsel them,’ because I woutd,consider. .
this lime the baby is going to be normal. This have been born with their brains out of the this a sheer waste of time."
(Response to this column can be sent to rasheeda@thecan be done through the ultrasound. Pioneer­ skull.
m in nr
S. )
Dr. Indirani had one such, case recently and hindu.co.in
or nt
faxed at 044-8535325.)
ing work done by Dr. Suresh and Dr. Indirani
Rashecda Bhagat

HEALTH SCAN

I

Suresh, another director of the Foundation, has
dramatically corrected different kinds of mal­
functions in the foetuses and helped mothers
have normal, healthy children.
But because imaging technology is being
used to eliminate female babies, what is forgot­
ten is that, through sonography, it is possible to
diagnose 50 per cent of the abnormalities relat­
ed to the central nervous system. This forms the
highest bracket of malfunctions in a foetus, followed by kidney disorders, cardiac ailments and
defects of the gastro-intestinal tract. "If used
■
■
1 ultrasound
’■ J can
— help us diagnose
judiciously,
85-90 per cent of life-threatening and about 70
per cent of major abnormalities in the foetus."
says Dr. Suresh.
For the first time in India, the Foetal Care
Research foundation (Ph: 044-8259556) has
set up a birth defects registry. "We are asking all
obstetricians and paediatricians to tell us when

>•

■

-J
■■

Q' ''

J

_J__

« Ji

REGISTERED Na DD-33004/94

HO stpqH0-33004/94

I

) \

ml

-^he (gazette of.^ndia
TF^nirrn

EXTRAORDINARY
IT--- ’1’1 1
PART II—Section 1
nifOTIT $ 5TWnf¥T<T
PUBLISHED BY AUTHORIT i

fatwrc 20, 1994/mi 29, 19ie
NEW DELHI, TUESDAY, SEPTEMBER 20, 1994'BHADRA 29, 1916

HO 74]
No. 74]

HUT H faTT TO
Serrate pngiwte given to Bus Pert iuonlerjtoit jt nwy be tikd^^ep^umpitotiou.

MINISTRY OF LAW. JUSTICE AND COMPANY AFFAIRS
(Legislative Department)

New Delhi, the 20/h September, 1994/Bhadra 29. 4916 (Saka)

l

lhe following Act of Parliament received the assent of the President
on the 20th September, 1994, and is hereby published for general tnfor
mation: —

t

the

L DIAGNOSTIC TECHNIQUES (REGULA,
PRE-NATAL
OF MISUSE) ACT. 1994
T1ON AND PREVENTION
f
No. 57 of 1994
[20lh September, 1994.]

An Act to provide for the regulation of the use of pre-natal diagnostic
techniques for the purpose of detecting genetic or metabolic d.sorders^r c^omosamal abnormalities or certain congemtal mal*■ nc nr ccx linked disorders and for the prevention of the

r

there with or incidental thereto.
Be it enacted by Parliament in the Forty-fifth Year of the Republic o’

India as follows:—

CHAPTER I
Preliminary
‘fWltT -tt-

X•

( JL I

’be'caW’'the"lPr^WMBB’©raglWSiic
JTinTXct'
X
A JhW V —— _

Techniques-

extent an'f
commeao
(2) It shall extend to the whole o£ India except the State of Jammu nieot.

* ' 19^.
(Regulation and Prevention of —
Mi^se) Act,

and Kashmir.

~

•j

- u •
1

THE GAZETTE OF INDIA EXTRAORDINARY

[Part H—

(5) It shall come into force on such dato ns the Central Government
by notification in the Official Gazette, appoint.
Dcfinitions.

2. In thia Act, unless the co itext otherwise requires,—
(a) “Appropriate Authority” means the Appropriate
appointed under section 1' ;

Authority

(b) “Board” means t ie Central Supervisory Board constituted
under section 7;
(c) “Genetic Counselling Centre” means a i institute, hospital,
nursing home or any place, by whatever name called, which provides
for genetic counselling to patients;
(d) “Genetic Clinic” means a clinic, insti ute, hospital, nursing
home or any place, by whatever name called, 'hich is used for con­
ducting pre-natal diagnostic, procedures;
(e) “Genetic Laboratory” means a labor; tory and includes a
place where facilities are provided for conduct ng analysis or tests
of samples received from Genetic Clinic for pre-natal diagnostic test;

(f) “gynaecologist” mea is a person who | ossesses a
post-gra­
duate qualification in gynaecology and obstetr cs;
....” means a person w io- -----------(g) “medical geneticist
possesses- a degree
or diploma or certificate
<
~ in i ledical genetics in the field of pre-natal
diagnostic techniques or has experience of not Isss than two years in
such field after obtaining—

(i> any dne of the rredicfil ^qualifications
the Indian Medical Council Act, 1956; or

recognised

under

102 of 195G.

(ii) a post-graduate degree in biologica sciences;
(h) “paediatrician” means a person who po sesscs a post-grad'.uJe

qualification in paediatrics;
(i) “pre-natal diagnosti : procedures” mean: all gynaecological or
obstetrical or medical proce lures such as ultras onography foetoscopy.
taking or removing sampl s of ^amniotic fluid, chorionic villi, blood
or any tissue of a pr^cnant womsin for being sent to a Genetic Laboiatory or Genetic Clinic for ;onducting pre-natal diagnostic test,
(j) “pre-natal

diagnostic

techniques”

includes all

pre-natal

diagnostic procedures and »re-natal diagnostic tests.
(k) “pre-natal diagnostic test” means ultrasonography or any test
or analysis of amniotic fl' id. chorionic villi, blood or any tissue of a
pregnant Ionian conducted to detect genetic o’- metabolic disorders o’
chromosomal abnormalities or epngential anomalies of naemoglobmo-

pathies or sex-linked diseases;

(l) “prescribed” means prescribed by rules made under ibis Act.
(m) “registered med-cal practitioner” means a medical practitioner
who nossesses any recog used medical quahficat on as defined in clause
■- - Council
i Act. 195G, and
(h) of section 2 of ;he Indian Medical
State Medical
Register;
whose name has been entered in a S-----ft * C'.-St'

I

102 of 195f

Sec. 1]

THE GAZETTE OF INDIA EXTRAORDINARY

3

(n) “regulations” means regulations framed by the Board under
this Act.
.

CHAPTER II
Regulation oe Genetic Counselling Centres Genetic Laboratories
and Genetic Clinics

3. On and from the commencement of this Act,—

(1) no Genetic Counselling Centre, Genetic Laboratory’ or
Genetic Clinic unless registered
------------- under
------ * this Act, shall conduct or
associate with, or 1help in, conducting activities relating to pre-natal
diagnostic techniques;
(2) no Genetic Counselling Centre, Genetic Laboratory or Gene­
tic Clinic shall employ or
cause to be
employed any person
who
does not possess the prescribed qualifications;

Regula­
tion of
Genetic
CounselHng
Centre
Geneti6'
I.abon0
lories and
Genetic
Clinics.

(5) no medical geneticist, gynaecologist paediatrician registered
medical practitioner or any other person shall conduct or cause to
be conducted or aid in conducling by himself or through :tny other
person, any pre-natal diagnostic techniques at .a place other than a
place registered under this Act.

CHAPTER III

Regulation of pre-natal djagnosuc techniques

4. On and from the commencement of this Act,—

(1) no place including a registered Genetic Counselling Centre
or Genetic Laboratory or Genetic Clinic shall be used or caused to
be used by any person for conducting pre-natal diagnostic techni­
ques except for the purposes specified in clause (2) and after satis­
fying any of the conditions specified in clause (3);
(2) no pre-natal diagnostic techniques shall be conducted except
for the purposes of detection of any of the following
abnormalities,
namely:—

(0 chromosomal abnormalities;

(u) genetic metabolic diseases;
(m) haemoglobinopathies;
(iv) sex-linked genetic diseases;
(v) congenital anomalies;

(vi) any other abnormalities or diseases as in iy be specified
by the Central Supervisory Board;
(3) no pre-natal diagnostic techniques shall be used or conducted
unless the person qualified to do so is satisfied that any of die fol­
lowing conditions are fulfilled, namely: —

(i) age of the pregnant woman is above thirty-five years;

Regulation
of pre­
natal
diagnostic
techniques.

L
-

4

THE GAZETTE OE INDIA EXTRAORDINARY

(») the pregant woman has undergone of
spontaneous abortions or foetal loss;

two

I.Part H-

or

more

(iii) the pregnant woman had been exnosed

oe.„s such „

(iv) the pregnant woman has a
family history of
retardation or [physical
’
deformities such as spasticity mental
or anyfc.
other genetic disease;
(v) any other condition as
may be specified by the Central 1
Supervisory Board;

W no person, being a relative
or the husband of the pregnant
woman shall seek or encourage the
conduct of any pre-nital diagnostic techniques on her except for the
purpose specified in clause
(“)•

t

Written
consent of
pregnant
woman and
prohibition
of commu­
nicating the
sex of
foetus.

5. (1) No person referred to L_
in clause (2) of section 3 shall conduct
the pre-natal diagnostic procedures
-J unless—

(a) he has explained all k iown side and after effects of
procedures to the pregnant woma i concerned;

such

(b) he has obtained in the prescribed form her written consent
to undergo such procedures in the language which she understands:
I
’
and

(c) a copy of her written consent obtained under clause (/>) is
given to the pregnant woman.
(2) No person conducting pre-natal
diagnostic procedures
shall
communicate to the p
---------- woman concerned or her relatives the
pregnant
sex
of the foetus by words, signs or in any other manner.

De.crmi.
Dation of
sex pro­
hibited.

G. On and from the commencement of this Act,—
(n) no Genetic
C
Counselling Centre or Genetic Laboratory
or
Genetic Clinic shall. conduct
----------; or cause
<
to be conducted in its Centre,
Laboratory or C
’
Clinic,
pre-natal diagnostic techniques including ult!»«. _______
rasonography, for 4the
purpose of determining the! sex of a »foetus;
(b) no person shall conduct or cause to be conducted
any pre­
natal diagnostic techniques including ultrasonography
fer the purpose of determining the sex of a foetus.
CHAPTER IV

Central Supervisory Board

Constitu­
tion of
Central
S upend
sory
Board.

7. (7) The Central Government shall constitute a Board to
be
known as the Central Supervisory Board to exercise the powers
and
perform the functions conferred on the Board under this Act.

(-) The Board shall consist of—
(a) the Minister in charge of the Ministry <or Department of
Family Welfare, who shall be the Chairman, c.v ojjicio;

5

THE GAZETTE OF INDIA EX 1RAORD1NARY

Sec. 1 j

the Secretary to trie Government of India in charge of the
(Department of Family Welfare, who shall be the Vlce-Uhulrnuui,
Vice-Chalrnuui,
ex-officio;
(c) two members to be appointed by the Central Government
represent the Ministries of Central Government in charge t)f
Woman and Child Development and of Law and Justice, ex-officio:

(d) the Director General of
Government, ex officio;

Health

(e) ten members to be appointed by
two each from amongst—

Services of

’he

Central

the Central Government,

(i) eminent medical geneticists;

(ii) eminent gynaecologists and obstetricians;
(iii) eminent paediatricians;

(iv) eminent social scientists; and
(v) representatives of women welfare organisations;
(f) three women Members of Parliament, of whom two snail he
elected by the House of the People and one by the Council of States:

(p) four members to be appointed by the Central Government
by rotation to represent the States and the Union territories, two in
the alphabetical order and two in the reverse alphabetical order:
Provided that no appointment under this clause shall be made
except on the recommendation of the State Government Or, as the
case may be, the Union territory;
(h)
(h) an
an officer,
officer, not
not below the rank of a Joint Secretary or
equivalent of
Government, in charge of Fatntlv Welfare,
equivalent
<__ the
— Central
who shall be the Member-Secretary, ex officio.

8. (1) The term of office of a member, other than an ex officio mem­
ber, shall be,—

(a) in case of appointment under clause (e) or
sub-section (2) of section 7. three years; and

clause (f) uf

(b) in case of appointment under clause (a) of the said
section, one year.

sub-

(2) If a casual vacancy occurs in the office of any other members,
whether by reason of his death, resignation or inabffity to discharge m
functions owing to illness or other incapacity, such vacancy shall be ftl e
hT the Central Government by making
making a fresh nppomtntcm nd the
member so appointed shall hold office for the tetnamder of the term
office of the person in whose place he is so appointed.

such functions as mav he
(3) The Vice-Chairman shall perform
t’me.
assigned to him by the Chairman from time to
' - r the members in the discharge
(4) The
The procettura
procedures w
to be
(4)
ue followed by
\
Of their functions shall be such as may be presented.

T erm. cf
office of
member*.

6
Meeting.'
of the
Board.

1HL GAZETTE OF INDIA EXTRAORDINARY

[Pakt II —

!)• (/) 1 he Board shall meet at such time and place, and shall observe
such rules of procedure in regard to the transaction of business at its
meetings (including the ' quorum at such meetings) as may be provided
by regulations:

Provided that the Board sliail meet at least once in six months.
(2) The Chairman and in his absence the Vice-Chairman shall preside
at the meetings of the Board.
(3) If for any reason the Chairman or the Vice-Chairman is unable
t0 attcnrt :inX. '"“PnB.PC the Board, any other member ehoserj by..
members present at the meeting shall preside at the meeting.

(4) AH questions which come up before any meeting of the Board
shall be decided by a majority of the votes of the members present and
voting, and in the event of an equality of votes, the Chairman, or in his
absence, the person presiding, shall have and exercise a second or casting
vote.

I

(5 ) Members other than ex officio members shall receive such allow­
ances, if any, from the Board as may be prescribed.
Vacancies,
etc., not io
* invalidate
proceed­
ings
of the
Board

10. No act or proceeding of the Board shall be invalid merely
reason of—

by

(a) any vacancy in, Or any defect in the constitution of,
Board; or

the

(b) any defect in the appointment of a person acting as a mem­
ber of the Board; or

(c) any irregularity in the procedure of the Board not affecting
the merits of the case.
Tempoi ary asso­
ciation of
persons
with the
Board for
particular
purposes.

11. (/) The Board may associate with itself, in such manner and for
such purposes as may be determined by regulations, any person whose
assistance or advice it may desire in canying out any of the provisions
of this Act.

Appoint­
ment or
officers
and
other em­
ployees of
tlic Benni.

its
’ 12. (/) For the purpose of enabling it efficiently t0 discharge
functions under this Act, the Board may, subject to such regulations as
on deputation or othermay be made in this bahalf, appoint (whether
wise) such number of officers and other employees as it may consider
necessary:

(2) A person associated with it by the Board under sub-section (/ )
for any purpose shall have a right to take part in the discussions relevant
to that purpose, but shall not have a right to vote at a meeting of the
Board and shall not be a member for any other purpose.

Provided tliat the appointment of such category of officers, as may
be specified in such regulations, shall be subject to the approval of the

Central Government.
_ J -or other employee appointed by the Board shall be
(2) Every officer
such
subject to l---- conditions of service and shall be entitled to such remuncration as may bc specified in the regulations.

Sec. 1]

THE GAZETTE OF INDIA EXTRAORDINARY

7

13. All orders and decisions of the Board shall be authenticated by Aulbcnlicalion of
the signature of the Chairman or any other member authorised by the orders and
Board in this behalf, and all other instruments issued by the Board shall other inbe authenticated by the signature of the Member-Secretary or any other sii umciiis
of the
olliccr of the Board authorised in like manner in tins behalf.
Board.

14. A person shall be disqualified for being appointed as a member
if, he—
(a) has been convicted and sentenced to imprisonment for an
offence which, in the opinion of the Central Government, involves
moral turpitude; or

Dibqualilications
for
appoint­
ment a.»
incrnhei.

(b) is an undischarged insolvent; or
(c) is of unsound mind and stands so declared by a competent
court; or
(d) has been removed or dismissed from the service of
the
Government or a Corporation owned or controlled by the Govern­
ment; or

such
of the Central Government,
financial or other interest in the Board as is likely to affect prejudicially the discharge by him of his functions as a member; or

,

(f) has, in the opinion of the Central Government, been assodated with the use or promotion of pre-natal diagnostic technique
for determination of sex.

15. Subject to the other terms and conditions of service as may be
prescribed, any person ceasing to be a member shall be eligible for reappointment as such member.
16. The Board shall have the following functions, namely: —
(i) to advise the Government on policy matters relating to use
of pre-natal diagnostic techniques;

I Hr.ibilily
of member
for reappointn>> nt.

Func­
tions
of the
Board.

(ji) to review implementation of the Act and the rules made
thereunder and recommend changes in the said Act and rules to the
Central Government;

(ill) to create public awareness against the practice of pre-natal
determination of sex and female foeticide;
(iv) to lay down code of conduct to be observed by persons
working at Genetic Counselling Centres. Genetic Laboratories and
Genetic Clinics;

(n) any other functions as may be specified under the Act.

CHAPTER V
Appropriate Authority and Advisory Committee

the
17. (/) The Central Government shall appoint, by notification in
the
Official Gazette, one or more Appropriate Authorities for each of
Union territories for the purposes of this Act.

Xppiopriatc
Autho­
rity and
\dvisory
c cminii'.'- *

l-W.

8

TH£ GAZE1TE OF INDIA EXTRAORDINARY

vi« .»BS«!SS-’M9*w*A» ■

LPart.I1—

(2) The State Government shall appoint, by notification in the Offi­
cial Gazette, one or more Appropriate Authorities for the whole or part
of the State for the purposes of this Act having regard to the intensity
of the problem of pre-natal1 sex determination leading to female foeticide.
(3) The officers appointed as Appropriate
section (/) or sub-section (2) shall be,—

Authorities under

sub-

V
/

(a) when appointed for the whole of the State or the Union
territory, of or above the rank of the Joint Director of Health and
Family Welfare; and
(b) when appointed for any part of the State or
the Union
territory, of such other rank as the State Government or the Cen­
tral Government, as the case may be, may deem fit.
(4) The Appropriate Authority shall have the following functions,
namely: —
(a) to giant, suspend or cancel registration of a Genetic Coun­
selling Centre, Genetic Laboratory or Genetic Clinic;

(b) to enforce standards prescribed for the Genetic Counselling
Centre, Genetic Laboratory and Genetic Clinic;

(c) to investigate complaints of breach of the provisions of this
Act or the rules made thereunder and take immediate action; and
(d) to seek and consider the advice of the Advisory Committee,
constituted under sub-section (5), on application for registration,
and on complaints for suspension oi cancellation of registration.
(5) The Central Government or the State Government, as the case
may be, shall constitute an Advisory Committee for each Appropriate
Authority to aid and advise the Appropriate Authority in the discharge
of its functions, and shall appoint one of the members of the Advisory
Committee to be its Chairman.
(6) The Advisory Committee shall consist of—

((i) three medical experts from amongst gynaecologists, obstericians. paediatricians and medical geneticists;

(b) one legal expert;
(c) one officer to represent the department dealing with infor­
mation and publicity of the State Government or the Union terri­

tory, as the case may be;

(d) three eminent social workers of whom not less than one
shall be from amongst representatives of women’s organisations.

(7) No person who. in the opinion of the Central Government or the
•• case may
•--r be,
hits been associated with the use
State Government, as the
L ------promotion
of
pre-natal
diagnostic
technique'for
determination of sex
or p____
shall be appointed as a member of the Advisory Committee.
‘‘■.feMs. .*■

(8) The Advisory Committee mav meet as and when it thinks fit m
{be^requesFoT'ffie' Ap^ro^^^
application for registration or any complaint for suspension or cancella­
tion of registration and to give advice thereon:

-^-rfwa

Sec. 1]

THE GAZETIE OF INDIA EXTRAORDINARY

9

Provided that the period intervening between any two meetings shall
not exceed the prescribed period.

(9) The terms and conditions subject to which a person
may be
appointed to the Advisory Committee and the procedure to be followed
by such Committee in the discharge of its functions shall be such as
may be prescribed.
w.. *4

w i.,x

Registration of Genetic Counselling Centres, Genetic Laboratories
and Genetic Clinics
18. (1) No person shall open any Genetic Counselling Centre, Genetic
Laboratory or Genetic Clinic after the commencement of this Act unless
such Centre, Laboratory or Clinic is duly registered separately or jointly
under this Act.

Registration
of Genetic
Counselling
Centres,
Genetic

Laboratories

(2) Every application for registration under sub-section (2), shall be'
made to the Appropriate Authority in such form and in such manner and
shall be accompanied by such fees as may be prescribed.

or

Geneti j
Clinic^:

(3) Every Genetic, Counselling Centre, Genetic Laboratory or Genetic
Clinic engaged, either partly or exclusively, in counselling or conduct­
ing pre-natal diagnostic techniques for any of the purposes mentioned in
• section 4, immediately before the commencement of this Act, shall app1y
for registration within sixty days from the date of such commencement.

(4) Subject to the provisions of section G, every Genetic Counselling
Centre, Genetic Laboratory or Genetic Clinic engaged in counselling or
conducting pre-natal diagnostic techniques shall cease to conduct any
such counselling or technique on the expiry of six months from the date
of commencement of this Act unless such Centre, Laboratory or Clinic
has applied for registration and is so registered separately or jointly or
till such application is disposed of, whichever is earlier.
Genetic
(5) No Genetic Counselling Centre, Genetic Laboratory•or
registered
Tinder
this
Act
unless
the
Appropriate
AuthoClinic shall be i^5----- - Clinic
is
in
a
position
to
rity is satisfied that such Centre, Laboratory or
such
equipment and standards as may
provide such facilities, maintain l
.

be prescribed.

‘y * shall, after holding an inquiry
19. (/) The Appropriate Authority
applicant has complied with all the
and after satisfying itself that the
rules made thereunder and having
requirements of this Act and the
Committee in this behalf, grant a
regard to the advice of the Advisory
prescribed form jointly or separately to
certificate of registration in the
t’
Clinic,
Genetic Laboratory or Genetic
the Genetic Counselling Centre,
as the case may be.

(2)
(2) IT. after the inquiry and after giving
heard to the applicant ayu
;satisfied that the applicant has
Committee, the Appropriate
Appropnate Authority
Author.t> J ££
• the rules, it shall,
not complied with the requirements <
the
application
for
‘recorded* in writing, reject
for regisfor reasons to be i----tration.

Cerliiicfito
of regis­
tration.

v->

10

THE GAZE PTE Ob INDIA EXTR AORDINARY

[Part H—

(3) Every certificate of registration shall be renewed in such manner
and after such period and on payment of such fees as may be prescribed.

I

(4) The certificate of registration shall be displayed by the registered
Genetic Counselling Centie, Genetic Laboratory or Genetic Clinic in a
conspicuous place at its place of business.

Cancella­
tion or
suspen­
sion of
registration.

20. (1) 1 he Appropriate Authority may suo moto, or on complaint,
issue a notice to the Genetic Counselling Centre, Genetic Laboratory or
Genetic Clime to show cause why its registration
should not be sus­
pended or cancelled for the reasons mentioned in the notice.

(2) If, after giving a reasonable opportunity of
of being heard
heard to
to the
the
Genetic Counselling Centre, Genetic Laboratory or Genetic Clinic and
having regard to the advice of the Advisory Committee, the Appropriate
Authority is satisfied that there has been a breach of the provisions of
this Act or the rules, it may, without prejudice to any criminal action
that it may take against such Centre, Laboratory or Clinic, suspend its
registration for such period as it may think fit or cancel its registration,
as the case may be.

(3) NotwidLslandwg anything
contained in
sub-sections (1) and
(2), if the Appropriate Authorily is, of the opinion that it is necessary
or expedient so to do in the public interest, it may, for reasons to be
recorded in writing, suspend the registration of any Genetic Counselling
Centre, Genetic Laboratory or Genetic Clinic without issuing any such
notice referred to in sub-section (1).
Appeal.

21. The Genetic Counselling Centre, Genetic Laboratory or Genetic
Clinic may, within thirty days from the date of receipt of the order of
suspension or cancellation of registration passed by the
Appropriate
Authority under section 20, prefer an appeal against such order to—

(i) the Central Government, where the appeal is
order of the Central Appropriate Authority; and

against

the

(ii) the State Government, where the appeal is against
order of the Stale Appropriate Authority,

the

in the prescribed manner.
CHAPTER VII
Offences and penalties

Prohibition
,

*-R. - •SlA -a of

YCXa®-

tisement
relating to
prc-nntnl
determina­
tion of sex
and punish­
ment for
contraven­
tion.

22. (1) No person, organisation, Genetic Counselling Centre

Laborato»r^?4SWfle^fiWc'shall issue
—» or cause to be issued any advertisement in <any
---- manner regarding facilities of pre-nntnl determination
of sex availablej at such Centre, Laboratory, Clinic or any other place.

(2). ,N? Person or organisation shall publish or distribute or cause to
be published or distributed
-------------- 1 ;any advertisement in any manner regarding
facilities of pre-natal determination
------ .i of sex
available at any Genetic
Counselling Centre, Genetic Laboratory, Genetic Clinic or any other

place.

Sec. 1]

<. k *4 *45

THE GAZEJ IE OF INDIA EX I R.Ai^RDlNARY

11

?xu^sR^.’3)aAny person*;wth®.con"
sub-section (2) shall be punishable with imprisonment for a term which
may extend to three years and with line which may extend to ten thousand
rupees.

Explanation.—For the purposes of this section, “advertisement” inclu­
des any notice, circular, label wrapper or other document and
also in­
cludes any visible representation made by m?ans of any light, so’imd,
smoke or gas.
23. (1) Any medical geneticist, gynaecologist, registered medical prac­
titioner or any person who owns a Genetic Counselling Centre, a Genetic
Laboratory or a Genetic Clinic or is employed in such a Centre, I.aboratory or Clinic and renders his professional or technical services to
or at
such a Centre, Laboratory or Clinic, whether on an honorary basis or
otherwise, and who contravenes any of the provisions of this Act or
rules made thereunder shall be punishably with imprisonment for
a
term which may extend to three years and with fine wh’ch may extend
to ten thousand rupees and on any subsequent conviction, with imprison­
ment which may extend to five years and with fine which may extend to
fifty thousand rupees.

I

I

OfFences
and
periollivs.

(2) The name of the registered medical practitioner who
has been
convicted by the court under sub-section (1), shall be reported by
the
Appropriate Authority to tho respective State Med'cal Council for taking
necessary action including the removal of his name from the icgister of
the Council for a period of two years for the first offence and permanently
for the subsequent offence.

(3) Any person who seeks the aid of a Genetic Councclling Centre.
Genetic Laboratory or Genetic Clinic or of a medical geneticist, gynaeco­
logist or registered medical practitioner for conducting pre-natal diagnostic
techniques on any pregnant woman (including such woman unless she wag
compelled to undergo such diagnostic techniques) for purposes o'her than
those specified in clause (?) of section 4. s^nll. bo punishable with impri­
sonment for a term which mav extend tn throe vrnre nnd with fine which
mav extend to ten thousand rupees and on any subsequent conviction with
imprisonment which may extend to five years and with fine which may

extend to fifty thousand rupees.
1 of 1872.

the
24. Notwithstanding anything in the Indian Evidence Act, 1072,
court shall presuma unless the contrary is proved that the pregnant
tundergo
.
woman has been compelled by her husband or the relative to
for abetshall
be
liable
pre-natal diagnotic technique and such person '
ment of offence under sub-section (->) of section 23 and shall bo puhishable for the offence specified under that section.
nny
25. Whoever contravenes any of the provisions of this Act or pro­
penalty b
rules made thereunder, for which no
no penalty
b -.• ’-een e’-..-where
term
me nt for
’
vided in this Act. shall be punishable with
I to
which
may
extend
which may extend to three months or with fine,
contraone thousand rupees or with both and in the erwe of continuing
vention with an additional fine which may C’fiend m uve hundred ru]kos
for every day during which such contravention confnv.ea a. lev convictton
for the first such contravention.

W. . (f-A

Presump­
tion in tho
case of
conduct of
pre-mtal
diagnostic
techniques.
IV unity
fo,- end:a*
venlion of
the pfovititons of tho
Act or rule*
tor which
r.o specific
punishment
is provided*

i

12
Offences
by com­
panies.
I

THE GAZETTE OF INDIA EXTRAORDINARY

[Part II—

26. (1) Where any offence, punishable under this Act has been com­
mitted by a company, every person who. at the time
the offence was
committed was in charge of, and ‘was lesponsible to, the company for the
conduct of the business of the company, ar. wr 'l as the company, shall be
deemed to be guilty of the offence and shall be liable to be proceeded
against and punished accordingly:
Provided that nothing contained in this sub-section shall render any
such person liable to any punishment, if he proves that the offence was
committed without hjo knowledge or that ho had exercised all due dilE
gence to prevent the commission of such offence.

£ 4. «fc..

I

(2) Notwithstanding anything contained in sub-section (7), where
any offence punishable under this Act has been committed by a company
and it is proved that the offence has been committed with the consent
or connivance of, or is attributable to anv neglect on the part
of. any
director, manager, secretary or other officer of the company, such director,
manager, secretary or other officer shall also be deemed to be guilty
of
that offence ^nd sball-be liable to be. proceeded against and . punished
accordingly.
Explanation,—For the purposes of this section,—
(a) “company” means anv bod'* corporate and includes a firm or
other association of individuals, and
(b) “director”, in relation to a firm, means a partner in (he firm. ,

I
1

Offence to
be cogni­
zable, nonbailablo
and noncompound­
able.

27. Every offence under
non-compoundable.

Cognizance
of offences.

28. (1) No court shall take cognizance of an offence under this
except on a comolaint made by—

this

Act ih:’ll be cognizable, non-bailable and

Act

’(«) the Appropriate Authority concomed. or any officer autho­
rised in this behalf hr the Central Government or State Government,
ns the case may be, or the Appropriate Authority; or

days
fb) a person who has riven nni:ro of not less than thirty
in the manner prescribed, tn the
Anpronr’nte Authority,
of the
alleged offence and of his in’ention to make a complaint to the court.
Explanation.—For the nurpnsp of »h’s clause, “person”
social organisation.

includes a

(2) No court other than that of n Metropoi;tnn Mari st rate or a Judiiindor
cial Magistrate of the first class shall try anv offence pumshable
this Act.

(^) Where a cnmn1:”’nf has Nonp made under (danse t.b) of
sub­
section G). the court mav. on demand hv such nerson. direct the Appro­
i'S
priate Authoritv to make available con’Ps of the relevant records in
possession to such |>erson.

THE. GAZETTE OF INDIA
EXTRAORDINARY
. .y.... .... . '

Sec. 1]

13

•__ ___________ *JV-

CHAPTER Vlll
Miscellaneous
all
29. (?) AU records, charts, forms, reports, consent letters and
other documents required to be maintained under this Act and (he rules
shall bo preserved for a period of two years or for such period as may bo
prescribed:
I

Maintcnancc^of
records.

Provided that, if any criminal or othcr
other proceedings are instituted
against any Genetic Counselling Centre, Genetic Laboratory or Genetic
Clinic, the records and all other documents of such Centre, Laboratory of
Clinic shall be preserved till the final disposal of such proceedings.
(2) All such records shall, at all reasonable times, be made available
for inspection, to the Appropriate Authority or to any other person autho­
rised by the Appropriate Authority in this behalf.

30. (/) If the Appropriate Authority has reason to believe that an
offence under this Act has been or is being committed at any Genetic
Counselling Centre, Genetic Laboratory ©r Genetic Clinic, such Authority
dr any oflicer authorised thereof in this behalf may. subject to such rules
as may be prescribed, enter and search at all reasonable times with such
necessary. such
assistance, if any, as such authority or officer ctrnsidcrs
or
Genetic
Clinic and
Genetic Counselling Centre, Genetic Laboratory
examine any record, register, document, book, pamphlet, advertisement or
seize-------the same if such Authoany other material object found] ttherein
-------- --and
----------l
to
believe
that
it
may
furnish evidence of the
rity or officer has reason t_ _
commission of an ofTice punishable ’under this Act.

2 of 1974.

’
1973 relating
(2) The provisions of the Code of Criminal‘ Procedure,
to searches and sciznrcs shall, so far as may Ibe. apply
... to every search oi
seizure made under this Act.
against
' i or other legal proceeding shall lie
31. No suit, prosecution
or
any
the
State
Government
or
the
Appropriate
Authority
the Central or t._ -----State
Government
or
by
the
Authority
officer authorised by the Central or
for anything which is in good faith done or intended to be done in pursuancc of the provisions of this Act.

Protection
of action
taken in
good faith.

32. (1) The Central Government may make rules for carrying out the

Power to
make mice.

provisions of this Act.
(2) In particular and without prejudice, to the generality of the fore­
going power, such rules may provide for

(i) (he minimum qualifications for persons employed al a regis­
tered Genetic Counselling Centre. Genetic Laboratory or Genetic
Clinic under clause (I) of section 3;
(/7) the form in which consent of a pregnant woman has to be

obtained under section 5;

(nr) the procedure to Ik followed by the members of the Central
functions under sub*
Supervisory
Supervisory IBoard
------- in the discharge of their
i
section (4) of section 8;
4-*-- «- a

Power to
search and
seize recoi ls,
etc.

«-■*

■■’p-

I;

i

14

THE GAZET I E OF INDIA EXTRAORDINARY

(fv) allowances for members other than cv officio
admissible under sub-section (5) of section 9;

[Pari II—

members

(v) the pcricxl intervening between any two inrrllnpq of din
Advisoiy CoiiimiUcc inkier the pimiso to sub section (/') of section 17;
(v/) the terms and conditions subject to which a person may be
appointed to the Advisory Committee and the procedure to be
followed by such Committee under sub-section (9) of section 17;

(vii) the form and manner in which an application shall be
made for registration and the fee payable thereof under sub-section
(2) of section 18;
(viii) the facilities to be provided, equipment and other stan­
dards to be maintained by the Genetic Counselling C entre. Genetic
Laboratory or Genetic Clinic under sub-scction (5) of section 18:

(Jx) the form in which a certificate of registration
issued under sub-section (/) of section 19;

shall be

(.v) the manner in which ami the period aftci which a certificate
renewal
of
of registration
registration shall be renewed and the fee payable for such
under sub-section (3) of section 19;
preferred under
(xi) the manner in which an appeal may be
- section 21;
\xii)
the period
period up
(xii) the
up to which records, charts, etc., shall be pre­
served under sub-section (1) of section 29;

I

i

(anti) the manner in which the seizure of documents, records,
objects etc . shall be made and the manner in which seizure list shall
be prepared and delivered to the person from whose custody such
documents, records or objects were seized under sub-sectton (I) ot
section 30;

I
I

Power
to make
regula­
tions

(xfv) any other matter that is required to be, or may be. prescribed.
33 The Board mav, with the previous sanction of the Central Gov-

inconsistent with the provisions of this Act ana
under to provide for—
the time and place of the meetings of the Board nnd the

■•‘•ft*

* Jeongs'and the number of members which shall form the quorum

i

under sub-section fl) of section 9;

r

mnv be temporarily associat(b) the tpanner in which a person
sulvscct-ion
(I)
of section 11:
cd with the Board under
(c) the method of appointment, the conditions of service and
the scales of pay and allowances of the onicer and other employees
of the Board appointed under section 12:
(d) generally for the cllieient conduct of the alTairs of the Board.
L

i

•h

Th

\

Vrr<

!

EDITORIAL

TOWARDS ERADICATION OF FEMALE INFANTICIDE:
ACHIEVEMENTS, FAILURES AND CHALLENGES

1

Historically, the practice of female infanticide
existed in many societies worldwide.1 In
colonial India,2 the British had initially tried
reform actions which later gave way to
coercive measures to check the practice. The
British fell that it was their Christian obligation
to stamp out such social evils. However, till
recently, little was known about the practice
in contemporary India. Over the last 12 years,
female infanticide in Tamil Nadu has received
notoriety both nationally and internationally.3

dependable anecdotal information on its
existence in Karnataka. Not surprisingly, the
same traditional method of killing is practised
over a thousand kilometres, all the way from
Madurai, southern Tamil Nadu to the coastal
districts of Andhra in the north. But lack of
systematic work and adequate concern among
social activists in the other southern states
has unfortunately led to the widespread
impression that it is only the Tamil women who
are killing their little girls.

This Bulletin is divided into three pans. The
first deals with the documentation of the
practice in different districts of Tamil Nadu
and comprises primarily micro-level studies.
The second section focuses on macro-level
documentation, on intervention strategies and
on the existing networks to combat ‘_h~ pr ctice
in Tamil Nadu. The final section is devoted to
female infanticide in Bihar and Madhya
Pradesh (henceforth MP). These states are in
different stages of evolution as far as
documentation and recognition of the practice
are concerned. In Bihar over the last five
years, Viji Srinivasan has exposed the practice
in several districts through Adithi's sister
organisations.4 Despite this, the Bihar
government continues to deny the existence
of female infanticide. MP is highlighted here
as little is known about the practice m me dldtc.
We hope that this collation of work from
several states will focus greater attention on
this despicable social evil in Bihar, MP and
elsewhere in India. Even in South India, this
author has knowledge of the practice in
several districts of Andhra Pradesh and has

This Bulletin brings together the contributions
of organisations, researchers, activists and
bureaucrats on this sensitive issue. We regret
our inability, to obtain contributions from
Oxford economist Barbara Harris-White and
feminist theologian Gabriele Dietrich, due to
lime constraints. Wc also failed to persuade
social activist Deva Manoharan (founder of
SIRD, Madurai) to overcome his modesty and
reflect on the crucial period between 1979 and
1986, when they first came across infanticide
in Usilampatti villages to the eventual
highlighting of the issue in the national media.
However, we have included papers by other
activists. They may appear to lack scholarly
elegance and erudition but their
understanding of the local context, and
contribution to the public discourse in Tamil
Nadu have been substantial. SIRD’s long and
continuous engagement with female
infanticide for two decades is noteworthy.
Regrettably, its contributions have not been
recognised in the recent literature on
infanticide. Its courageous opposition of the
State’s coercive efforts has been inspiring.

4

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SEARCH BULLETIN July ■ September J 998

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1

Despite limited resources. Renganathan of
VRDP mobilised various NGOs in and around
Salem on the issue of female infanticide. That
this was done in mid-1990s, when Jayalalitha’s
government was asserting that the practice
had been eradicated in Salem
always be remembered.

Obviously, any anthology would have its
limitations. We have not even managed to
cover all the NGO efforts; for instance, CSG
(Salem), AID India (Dharmapuri), or Pradhan
(Madurai), let alone doing justice to such
eminent Tamil writers as Rajam Krishnan etc.,
or to the well known film Director Bharatiraja.
Since we have limited ourselves to the English
language, the contributions jn Tnmn
been regrettably left out. Further, the efforts
of donor agencies who have enabled much of
the work presented have not been considered.
Apart from traditional agencies such as
UNICEF. DANIDA etc., there are newer
donors like the National Foundation of India
who are supporting-work on female
infanticide. The critical role of the media also
has not been given due recognition here; apart from including some excerpts from
Natarajan’s review? The media have
sensationalised female
exacerbated repressive actions by the state.
But. one positive consequence of/nedia
highlighting female infanticide in Tamil Nadu
in 1992 has been that it certainly provoked
some questions in the Parliament, which has
led the Government of India to sponsor several
research studies on declining child sex ratios,
such as Premi & Raju s in Madhya Pradesh.
Regarding the use of alternate communication
media to combat infanticide, we include the
contribution of the MS Swaminathan Research
Foundation. However, we have not captured
here the use of street theatre in Dharmapuri
district for social mobilisation. This excellent
initiative was led by Chunkath and the Tamil
Nadu Science Forum activists.6

I

I will place this collection of papers in a
broader context by presenting a brief and

j

SEARCH BULLETIN July - September

I

selective overview of the past work on female
infanticide in lamil Nadu. These articles
dem o ns t rate that many committed
organisations and individuals contributed
towards exposing the practice and raisin?
consciousness in lamil Nadu. We have thus
come a long way over the last 15 years. From
the persistent denial of the practice by the
state in the mid-1980s to the grudging
admission of its existence “only in
Usilampatti in the late 1980s and eventually
to the formal recognition by the government
in 1992, when Ms Jayalalitha was the Chief
Minister. And thanks to the perseverance of
Chunkath and Athreya, we also have
information on the high risk area? <’nd
estimate of the contribution of female
infanticide towards the total infant mortality
in Tamil Nadu.7 The earlier assertions, that 75
per cent of the newborn girls in the Usilai
Government Hospital were killed in 1986 and
that 50 per cent of female infants born in Salem
in 1992 were victims of infanticide, are
demographically implausible. Nevertheless,
we should not forget the historic role these
organisations played in drawing the attention
of policy-makers and society. Perhaps these
er naramrior -

.u .

-

.•

•

•

exuberance or the desire of journalists to
provide authenticity' to a phenomenon that
was not believed to exist. Unfortunately, such
overstatements served to cast doubt on the
very existence of the practice-in the
demographic community. A dispute that still
remains is regarding how recent the origin of
the contemporary practice is.3 There are
claims that female infanticide is a recent
phenomenon, about two decades old. From
extensive Held work in villages since the.mid------ -

duu lilCllKljng

living in villages for five years, this author
has learnt that the practice has existed at least
for the past six decades. Unquestionably, its
incidence has increased as is evident from
dramatic declines in preschool child sex ratios
in several districts against girls in the 1981
and 1991 national censuses.

1998
5

■

I

Despite the recognition of the practice and
While celebrating the achievements related to
efforts to document it. our understanding of
the recognition of female infanticide in lamil
the causes for the sudden spurt in female
Nadu, ids also necessary to simultaneously
infanticide in Tamil Nadu over the last two
highlight the significant failures. To begin on
decades is limited. As Harris-White points
a personal note?some of us who were involved
out, 'the terrain of theory is quite rich while
in getting the practice recognised were so
the actual evidence is meagre. 9 Another
obsessed with that mission since mid eighties
concern is that we would not even know if the
that we failed to recognise that infanticide
practice is really declining in a particular region
could be complemented/replaced by foeticide
as documentation efforts of most NGOs are
as has happened in north-west India and
weak and inadequate. To wait until the 2001^
elsewhere in East Asia including China. Only
census may mean wasting four more years. If
in the early 1990s. when the sex determination
some preventive strategies prove effective,
(SD) clinics had already emerged in several
then it will be regrettable that others cannot
district headquarters, did we wake up to the
be inspired or motivated to emulate such
possibility of female foeticide being practised
successes. Meticulous documentation,
by rural women. Our complacency was in part
unfortunately, has been a weak point of NGOs.
due to the fact that unlike in the north or west
The sincerity and dedication of their efforts
India, there was a lag of about a decade before
are considered adequate. (See note 10 for
the SD clinics appeared in Tamil Nadu. We
elaboration).
mistakenly presumed that such bad practices
as female foeticide would not emerge in the
A serious setback in the female infanticide^
south where the status of women has
prevention efforts in Tamil Nadu has been the
- traditionallv been higher than that in the north.
coercive action by the state government. This
Unfortunately, even today there is inadequate
was blatant during the regime of Ms
recognition of the rapid spread ot foeticide in
Jayalalitha (1991-96). Regrettably, the hope
the state among the activists and policy­
that coercive methods would be abandoned
makers. Not only is there widespread
by the successor government has been belied.
awareness about foetal sex determination in
Bureaucrats, and even the Health Minister,
the rural society, but women in even remote
have been declaring their intent to frame new
rural areas have started to selectively abort
coercive legislation, which includes
female foetuses. The present rural incidence^
penalising men?11 The role of men in
may be negligible, but the rate of spread of
infanticide is obvious but I would like to
the new technology, its increasing utilisation
emphasise the ineffectiveness of coercive
by rural women and its impact on sex ratios in
actions to reduce the practice. The greatest
’ the future is worrisome. Further, the misuse
danaer we have repeatedly observed over the
of this technology has served to legitimise
last decade in Madurai and Salem districts is
the practice of female infanticide in the minds
that repressive actions interfere with the
of rural people at large. The implementation
ability to know what is happening in the
of the 1994 national law banning misuse of
villases and of course with positive actions
foetal sex determination testing has been
to prevent infanticide. The conspiracy of
virtually ignored in lamil Nadu. As of August
silence on infanticide that an environment of
fear created by state terror imposes on society
1998. not even a single case has been filed
against the doctors who are blatantly violating
is often misunderstood to be the absence of
the practice. Also, criminal law is repressive
the law. Contrast this with the fact that as of
January 1997, over 50 cases of female'
against the poor. Furthermore, efforts at new
infanticide were reportedly registered by the'
legislation targeting men would likely lead to
police to victimise the helpless families?
SEARCH BULLETIN July - September 1998

6

t

even more violence on women. In this regard,
the paper by Rajivan, who was the District
Collector of Madurai from the early to the mid
1990s. is relevant. Following a complaint
lodged by the Indian Council of Child Welfare
on a case of female infanticide in Usilai taluk,
he asked the police to act. The mother of the
infant, Karuppayee. a poor rural woman was
arrested and later sentenced by the Madurai
court to life imprisonment. She spent years
in jail. SIRD is presently involved in helping
this unfortunate victim’s appeal in the Madras
High Court. We admire Rajivan’s honesty in
confessing that very little can be achieved by
police action except for generating bitterness
amons young mothers caught in a social
svstem.... He further admits that coercive
actions are not relevant where complex social
attitudes are concerned. We hope Rajivan s
remorse will prompt officials to reconsider
repressive measures.

*

Efforts to frame such new legislation in tamii
Nadu also diven attention from the energies
needed to deal with the increasing practice ot
female foeticide. Are the politicians and
officials afraid to acknowledge the illegal and
unethical practice of female foeticide and
indulging in diversionary tactics oecause of
the considerable clout of the doctors?
Besides sex determination by ultrasound
scanning, we have come across the use of
sophisticated methods of sex determination
like sex preselection in Tamil Nadu. Why is
the state and its officials silent about
advertisements of such sophisticated
techniques that are in gross violation of the
1994 Act, which bans foetal sex determination?
In Bihar, the burden on NGOs like Adithi is
much heavier due to the non-functioning of
the health and nutrition sectors in many pans
of the state. Unlike in Tamil Nadu, it is not
possible even to obtain dependable
information on the status of girl children from
government sources such as Primary Health
Care or Ansanwadi centres in Bihar. The
quality of such data in Tamil Nadu is superior
SEARCH BULLETIN July - September 1998

to that senerated by Bihar or Madhya Pradesh.
Therefore, we do hope that the weaknesses
of documentation observed in Tamil Nadu s
NGO sector will not be repeated in Bihar. The
purpose of highlighting infanticide in MP is
not to claim that female infanticide is
widespread in every part of this big state which
has a significant tribal population. We
sincerely hope this study will not be dismissed
by MP officials on the grounds that it only
exists in Bhind, which is anyway on the
fringes of the state. I have been informed of
the existence of the practice as early as 15
years'ago in Hoshangabad district, which is
near Bhopal. It is necessary to highlight that
Madhya Pradesh was the first Indian state to
prepare a -Human Development Report’.
Given such unique progressive initiatives, we
hope that the state will deal sensitively with
female infanticide.

Stephen describes the different networks
workins asainst female infanticide in lamil
Nadu. But despite the existence of these
networks, there has been no truly collective
action towards eradication of female
infanticide/foeticide. We hope that the
various networks, organisations, mass
movements and individuals interested in
women’s issues will be able to transcend their
personal and ideological differences so as to
initiate united campaigns against female
infanticide, foeticide and other forms of
violence against women. Gender sensitisation
efforts are imperative for reducing the
intensification of son preference .in Tamil
Nadu. Discrimination against women will
lessen if society gives them their due share in
education, economic opportunities, property
rights and political power. The Government of
India has to disseminate the findings of the
studies on declining child ratio commissioned
in several states in the early 1990s. It urgently
needs to finalise the guidelines of the ‘Girl
child scheme’ announced by former Prime
Minister I.K. Gujrai on the 50th anniversary
of Independence in August 1997. This, when

7

implemented, would lead to fertility reduction
with gender equity. The least that other stale
governments could do immediately is to follow
Tamil Nadu’s example and recognise lhe
existence of female infanticide. This will
provide space for activists, NGOs and socially
aware officials to delve deeper and initiate
prevention programmes that governments can
review and extend to all other areas at risk.

Dr. Sabu M. George
email - sabumg@md2.vsnl.net.in

Acknowledgements

I would like to thank Mr. F. Stephen for giving
me (he privilege of editing this SEARCH
Bulletin. The contributions of Drs. V. Benjamin
and C.R. Soman are gratefully acknowledged.
Sabu’s recent work has been supported in part
by Samvada and UNICEF.
Notes
1. See the paper by George.S.; R. Abel and B.D.
Miller included here.
2. See the paper by M.K. Premi and S. Raju for a
consideration of the colonial census reports.

3. George. S.M. ‘Female Infanticide in TamilNadu.
India: From Recognition Back to Denial?’
Reproductive Health Matters, No. 10, November
1997. pp. 124 -132.

4. See the paper by Suman K. Srivastava included
here.
5. Natarajan. S. Monograph No. 6, MSSRF.

6. Athreya. V. ‘Social Mobilisation for Change'.
Frontline, 9 October 1998; pp. 94-97.
7. Athreya. V.B. and S.R. Chunkath. ‘Gender
Discrimination Strikes: Disquieting Aspects of
Early Neonatal Deaths in Tamil Nadu’. Frontline.
I 1 July 1997.

8. Negi, E. Monograph No. 5 MSSRF. p. 25.

9. Harris-White. B. 'Development and Death:
Adverse Child Sex Ratios in Rural Tamil Nadu'.
Frontline, 4 April 1997.

8

10. To illustrate a typical example of poor
documentation, I use VRDF village data from
Renganalhan’s paper. (Tills is a generic observation
which I have come across repeatedly over the last
13 years from so many NGOs). The comments
are on Table 6, which gives the number of births
and deaths sexwise for the period 1995 to 1997 (I
am ignoring 1998 as it is only for 6 months and,
without knowing the seasonality of births, it is
hazardous to extrapolate from 6 months to a year).
The variation of the total number of annual births
from 215 to 131 is very large and most unlikely to
be natural in normal Tamil villages (where migration
is minimal). Perhaps in the year 1995 there has
been an overestimate of the actual births (i.e.
children born in the previous year were included
in 1995). Another likely possibility for the year
1997 is that a disproportionate number of females
who died prematurely were missed. Having
personally lived in villages for 5 years and followed
thousands of pregnancies prospectively, I know
how difficult it is to ensure that every pregnancy
outcome is recorded. Therefore one has to
undertake an independent audit to ascertain the
completeness of reporting of pregnancy outcomes.
It will be helpful if NGOs could report the
proportion of pregnancy outcomes missed in their
villages. It is important to know what proportion
of the actual number of female deaths were not
recorded. In the absence of such meticulous
estimates it is not possible to infer that lhe reported
drop in Fl rate from 10.23 to 6% was true, i.e. that
there is indeed a declining trend in female
infanticide, particularly in such a small study
population. Even when one is very meticulous, it
is hazardous to interpret small changes in incidunce
in small populations as there can be random
fluctuations from year to year. This is where a
collective of NGOs can be helpful if all of them
give adequate emphasis to good quality perspective
monitoring of pregnancy outcomes. Disaggregation
of natural deaths sexwise (or male and female
survivors) is suggested in future (this is not
provided in Table 6). Further, female infanticide
estimates should be calculated as a per cent of total
female babies born, and not as that of total births.
1 1. Staff Reporter. 'Female Infanticide Spreading
to New Areas.', The Hindu, Chennai, 7 January
1998.

SEARCH BULLETIN July - September 1998

■ /7

I
m I Rl 'it c r * ' r «

Scanning for death
In a region in Tamil Nadu where female infanticide is endemic, increasing instances of foeticide
employing modern tools of medical technology raise a range of questioms.
“natural”. Women waiting outside a scan
over a hundred scan centres.
centre in Thirumangalam village spoke of
All the scan centres in Usilampatti taluk
one instance in Pudipuram village in operate illegally - they have not obtained cerwhich aal
which
baby girl had died within five tificatesof'SXtrad
~ itration from the appropriate
days of
of birth:
birth: she
she had
had been
been starved
starved to
to
days
authority
as
required
under law. For Rs. 150,
J__ ; ;In____
death.
Kumuli village, a 15-day-old girl
had been buried alive. And in Sadachhatti die centres scan foetuses to determine the sex
- in blatant violation of the law and medical
village, a baby girl was left in front of a
- anu uiscreeuy oisciose me one b.
ethics - and discreedy disclose the one bit of
table fan running at full speed. She died information thatZd^deXhe" o
within a few hours.
• foetus
‘
the
will be allowed to live: its gender.
__
, female xwvueiue
Increasingly,
foeticide »
is ucm
being
widely practised in many villages in Madurai
• , MERGING from the scanning room,
district
district and
and the
the neighbouring
neighbouring Salem
Salt district, i vRajathi is crying uncontrollably: it is a girl,
Advances
medicaltechnology
technology are being Certain that she will not be able to face her
---------- inin medical
misused to aid the practice: in 1recent 7years husband and mother-in-law, she decides to
^Vli aa proliferation
E1U1U1
there has been
in the--------number.■ go back to her parents’ village and abort the
of ---------------scan centres even
in ii remote villages that foetus. Some of the women in the village will
otherwise have only the most 1rudimentary help her; their methods will be crude and will
public health
, facilities.
itt..There are 13 scan
—lcen" probably put Rajathi sown life at risk, but her
tres in and around Usilampatti taluk - three mind, conditioned by traditional social valin ^m, two at ues that look upon female children as a “burHurumangdam, and one each at Andipatti, den” on the family, is made
Vadialagundu and Kallupatti. In Madurai
Amaravathi too has discovered that
city, 40 km from Usilampatti town, there are she bears a girl child, but unlike Rajathi,

ASHA KRISHNAKUMAR
in Usilampatti

I

A 1 noon on an unusually hot
/^November
>vember day,
day, the
the village
village street
street is
is
deserted
---- / for the
1 occasional
’
* cyclist,
"
J except
In one particular building, however,'there
is a throng of people, most of them
tneir numbers so .large
o thar they
women, the.r
almost spill out on to the street. Here is
an ultrasound scan centre which offers
pre-natal diagnostic facilities, ostensibly
to monitor the health of the foetus but, in
many cases, to determine its sex for a deadly purpose.
Over by a corner, quite oblivious to
the presence of others, Sarasamma, who
has just had her foetus scanned, and her
mother-in-law are arguing loudly, but in
a chilling matter-of-fact tone, about when
to snuff out a life: should the female foe­
.
tus that Sarasamma bears be killed in i*__
rhe
womb or should they wait a few months
for the baby to be born and then starve
her to death?
This is Usilampatti taluk in
Ua'
Madurai district in southern
1 amil Nadu, where girls are born
'--A
to die - or, as is increasingly the
ase, are denied even the chance
to be born. Female infanticide is
known to be endemic in the area
but the State Government claims
that such instances have declined
following the introduction in
1992 of a number of schemes to
address this ‘sociological’ crime.
However, the situation is still
serious: despite awareness cam­
paigns organised
by the
Go <?rnment and the fear of the
law following the arrest in 1996
!
of Karupayee on charges of
I.
■ I
killing her girl child, female
infanticide continues to be prac­
tised here widely.
As I discovered during a visit
to some villages in Usilampatti
taluk in mid-November, many
mothers seem to starve or suffo­
cate their female children to
tAhe-5^
death, maiung the deaths appear the
most rudimentary public Health fa’cllitteishave Pr0,!ferated in Vil,a®es that otherwise have

.Illi

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FRONTLINE, DECEMBER 18, 1998
109
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she contemplates abortion with noncha­
lance. “Of course, I will abort the foetus,”
she says. “Rajamma, who retired as a nurse
in the Usilampatti Government Hospital,
will perform the abortion, as she has done
for many others, charging less than what
the private hospitals charge.”
In
Ayankoilpatti,
Ichampatti,
Kalyanipatti, Thummakundu, Linganayakanpatti,
Pudhipuram
and
Pothampatti villages, women who are
even seven months into their pregnancy
have gone in for abortions after a scan
revealed the sex of the foetus. In Vadipatti
village, a 25-year-old woman died while
trying to abort her seven-month foetus.

of India Gazette Notification states:
“Every clinic shall prominendy display on
its premises a notice in English and in the
local language or languages for the information of the public, to the effect that disclosure of the sex of the foetus is
prohibited under law.”
Under Section 10(1) of the Gazette
Notification, before conducting any prenatal diagnostic procedure, scan centres
are re<iquired to obtain from the pregnant
woman a written consent “as specified in
Form G, in a language the pregnant
woman understands”. By signing Form
G, the pregnant woman “undertakes not
to terminate the pregnancy” if the pre­
natal tests disclose no foetal deformity or
disorder. She is further required to state
that she “understands that the sex of
< the
foetus will not be disclosed” to her.
Owing to poor implementation of the
Act, however, sex-determination tests
continue to be carried out with impuni­
ty. And sex-specific abortions, assisted in
many instances by doctors and paramed­
ical personnel, continue to be performed,
sometimes at great risk to the woman. The
long-term sociological consequences of
* " ’ unethical
’‘
’
these unlawful,
acts are serious
in the extreme.

Tamil Nadu - Salem (849), Dharmapuri
(905) and Madurai (918) - are revealing.
Salem district, in fact, recorded the low­
est juvenile sex ratio in the country. The
three districts accounted for 41 out of 46
blocks in Tamil Nadu which had a rural
juvenile sex ratio of900 or less. The State
Government’s claim that instances of
female infanticide have declined in
Usilampatti taluk after the initiation of a
number of schemes in 1992 is not borne
out by data compiled for 1995 by prima­
ry health centres in the State. Female
infant mortality rate (defined as mortali­
ty in the first year per 1,000 females
born) in Dharmapuri district was 100.1;
in Madurai it was 70; and in Salem it was
85.4. The figure in respect of the whole
ofTamil Nadu was 44.3. Specifically, the
early
# neo-natal female mortality
. rate (that
is, death within six days of birth) in
Dharmapuri district was 76; in Madurai
it was 43.4; and in Salem it was 60.4."
State average was 24.

OEX-DETERMINATION tests and,
Oconsequently, female foeticide became
known in India in the 1970s.
Amniocentesis, an invasive sex-determi­
nation test, was prevelent in the 1970s and
the early 1980s in Delhi and spread rapid­
ly to other parts of the country, particu­
larly to Maharashtra (Frontline, July 9-22,
I SET out from Madurai for Usilampatti
1988). According to some independent
-i taluk along with members of the Society
estimates, of the 8,000 abortions done in
for Integrated Rural Development
Maharashtra in 1987, 7,999 involved
(SIRD), a voluntary organisation which
female foetuses. With public outrage
has been active in the area for 20 years and
against amniocentesis mounting, the
which in 1986 first highlighted the
Maharashtra Government enacted a law
A
CCORDING
to
Census
of
India
instances of female infimticide in the
on May 10, 1988 to regulate pre-natal
diagnostic centres. None of the other 1 kdata for 1991, the sex ratio (defined region. Theyr are: SIRD field director M.
uiv Central Government, ..v
..
___________________
_____
and field
as the number offemalesrper
1,000 males) Vasu
T------------- officers C. Maunam, P.
States Vi
or the
however, did so. It was only in 1994 that the for the juvenile population (O-o age Pavaiam and C. jayaniam. The economy
Pre-Natal Diagnostics (Regulation and group) of Tamil Nadui was 948, against of the region is primarily agrarian, and as
_ However, the
we approached Usilampatti town, the
t national average of945.
Prevention of Misuse) Act was put in the
of
three
districts
in
landscape turned from fertile to dry. The
figures
in
respect
place.
disparity in living condiUnder the Act, pre­
tions in the different areas
natal diagnostic scans are
5
was striking. In the fertile
permitted solely to detect
2 areas, the houses were regu­
genetic abnormalities at
lar constructions and
1
the pre-natal stage. The Act
television
sets,
refrigerators,
—
.^7
forbids sex-determination
mixies, grinders a^d sofa
tests. Chapter III Section
sets. In contrast, in f ,»e dry
6(b) of the Act states: “No
-.
areas, the houses. were
person shall conduct... any
thatched structures and had
[
..
•:
pre-natal diagnostic tech­
few belongings.
niques ... for the purpose of rX
We were to meet a few
determining the sex of a p ■ M
SIRD members; since most
DEVffKI
.
I
foetus.” Further, Chapter
of them were apprehensive
III Section 5(2) of the Act
about talking to us in their
states: “No person con­
villages, we had arranged to
ducting pre-natal diagnos­
meet them at the SIRD
tic
procedures
shall
office at Periyasemmetcommunicate ... the sex of
tupatti, two km from
the foetus by words, signs
Usilampatti town. By die
or in any other manner.”
time we reached the village,
The Tamil Nadu
28 women from nine sur­
Government framed the
rounding villages had gath­
rules and gazetted the Act
- . . ered. Initially most of them
in January 1996. Section
claimed that they had never
17(1) of the Government A scan centre in Madurai.

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FRONTLINE, DECEMBER 18, 1998

“Cradle babies” at Usilampatti In 1994. The “cradle baby scheme” fizzled out.

gold, a IV set, sofa, cot, cupboard,
mixie and grinder. How can I afford
all this?”
According to Maunam, the prac­
tice of giving huge dowries began in
the early 1960s. With the opening of
the Vaigai dam, there was a boom in
the agricultural economy in the
region; some people were better
equipped to benefit from it, and
income
disparities
widened.
Consanguineous:.marriages gave way
to a system whereby the rich offered
huge dowries in order to get “good
bridegrooms” from outside the fami­
ly. The “offers” were soon replaced by
“demands”, which over time became
increasingly unrealisable for all but the
most affluent.
Gender disparity manifests itself
in several other ways in a patriarchal
society and contributes to the shaping
of a mindset that perceives girl chil­
dren as a “burden”.
In 1992, the State Government
acknowledged for the first time the
seriousness of the problem of female
infanticide. It introduced several
schemes, including one under which
parents could abandon “unwanted”
girl babies in cradles kept in noon meal
centres, primary health centres and
orphanages; the babies would then be
brought up in State-run orphanages.
About 50 babies> were thus found aban­
doned in Usilampatti. But the scheme fiz­
zled out because many babies that were
“adopted” by the State died. According to
data compiled by the Social Welfare
Department, 133 babies were found
abandoned in cradles in Usilampatti and
Salem between 1992 and 1996. Of these
70 died.
Another scheme, under which the
State Government was to invest Rs.2,000
in the name ofevery girl child born in poor
households, was not implemented until
1997.

committed female infanticide or foeti- houses with the help of hospital nurses, In
cide. But even as they narrated instances Vadipatti village, a six-month foetus was
in “other families”, some of them broke aborted thus in October. Early in
down and confessed to having committed November, a five-month foetus was jsaid
similar crimes.
to have been aborted in Iyyamkoilpatti by
Santhosam from Sadachipatti village a retired government hospital nurse.
said: “Female infanticide still goes on, but
A few others go to Madurai and
after the arrest of Karupayee the methods undergo abortions at one of the dozens
used are different.”
of private hospitals there.
Rasamma of Kalyanipatti village
explained: “We no longer kill the girl baby CEVERAL sociological factors influip of the oleander Oence
O
vith the poisonous sap
the preference for male children
plant as traces of the poison can be detect- that is at the root of female infanticide and
ed (in post-mortem examinations). We female foeticide. The heart-rending tale of
make the death appear natural. For Thedaselvam exemplifies some of them.
instance, we starve the baby to death or Frail and anaemic, she had tried to abort
asphyxiate it... Women who cannot afford her five-month-old foetus but her hus­
a scan or an abortion prefer these meth­ band, who had lost both his legs in an acci­
ods.” Poomani of Ichampatti village said dent, had prevented her. FI is overriding
that in some instances, the baby was concern was that ifshe died owing to comCOORD ING to the women of
buried alive within the compound of the plications arising from an improper abor­
Usilampatti, following the arrest of
house.
tion, there would be no one to look after Karupayee, fear of the law prompted a
Among those who go in for sex­ him and their eight-year-old son and six- decline in the reported instances of female
determination scans and learn that the sex year-old daughter: the family' survives on infanticide. It was then that scan centres
of the foetus is female, not everyone opts the Rs. 15 a day
, that Thedaselvami earns mushroomed in the region,roffering the
for or can afford an abortion in a hospi- as a ffarm labourer. But Thedaselvam
1
facility for early detection of the sex of the
tai. Annakodi recalled that in Pothanpatti asked tearfully, “What will I do if this too
foetus.
village a woman tried to abort her female i:is a girl? The expenditure we incur on a
According to T.T. Guhan, Deputy
foetus with an oleander stem. The abor­ girl all through her life is enormous ((there
*
Director (Administration), Directorate of
tion was incomplete and the woman are six occasions on which ceremonies are Medical and Rural Health Services,
developed high fever and fits. She was to be performed for a girl). For the mar­
Chennai, none of the scan centres in
rus’ied to hospital but died a day later. riage, which entails a huge expenditure,
Usilampatti is registered with the
Soi' e women undergo abortions in their we have to give at least 10 sovereigns of Directorate, which i;
is the Appropriate
FRONTLINE, DECEMBER 18, 1998

111

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Authority for the imple­
A third woman doctor, who offers
Sex-specific abor­ to an abortion regardless
mentation of the Act.
of the accuracy of the sex scan facilities in Usilampatti town, said
tions, assisted in
The Advisory Comm­
determination.
that she performed four or five abortions
many instances
ittee set up to aid and
a day. Asked about the ethics of sex-spe­
advise the Appropriate
WOMAN doctor cific abortions, she said: “I offer the poor
by doctors and
Authority
met
on
who has been prac­ a place where the abortion can be conparamedical per­
November 3; it decided
tising in Usilampatti ducted without health risks to the mothsonnel, continue
to send out notices to the
town for 10I years said er. Otherwise, these poor people will be
scan centres that have
that she handled about 25 at the mercy of quacks.”
to be performed,
not been registered with
abortion cases a month She claimed that there was no need
sometimes at
the
Appropriate
mostof them incomplete for scan centres to be registered as scan­
great risk to the
abortions,
pre-marital ning was an out-patient procedure. She
Authority.
Most of the scan
woman. The long­ pregnancies and sex- admitted that she disclosed the sex of the
abortions - after foetus orally or symbolically or through
centres in Usilampatti
term sociological selective
securing in each case the her assistants. The number of requests for
have been established by
consequences of consent of the parents or scans had increased in the last two or three
doctors who appear to
the husband. Her clinic years, she noted.
have little hesitation in
these unlawful,
A private scan centre which was
does not have scanning
disclosing the sex of the
unethical acts are facilities but she refers her opened in 1996 in Usilampatti town is
foetus - which they do
serious in the
cases to centres in run by some doctors. One of them, whom
either orally or by scrib­
Madurai and Usilampatti we met at the centre, insisted that there
bling ‘xx’ (referring to
extreme.
town. Even as we were was no need for the scan centre to be reg
the female chromosome
pattern) on a piece of paper. Shockingly, talking to her in her clinic, a man repre- istered or for the pregnant woman’s con­
doctors who run the scan centres and senting a scan centre in Usilampatti sent to be obtained for a scan. The centre,
those who perform abortions seemed to brought her share of Rs. 25 for every he said, was started as there was a demand
for it in Usilampatti. He said that 75 scans
be unaware of the Act and the fact that patient she referred to the centre,
She
initially
claimed
that
the
sex
of
the
a month were performed at the centre; he
their actions in performing sex-determi­
foetus
was
never
disclosed,
but
on
repeatconceded that the sex of the foetus was
nation tests and disclosing the sex of the
foetus constitute a punishable violation of ed questioning admitted that the infor- disclosed orallyr to some women.
Another scan centre in Arasanedi, set
the law. Chapter II Section 3(3) of the Act mation was communicated orally to some
up a few months ago, performs at least 15
women.
states: “No medical geneticist, gynaecol- women,
According to her, most of the scans a day. It is patronised by many peoogist, paediatrician, registered medical
practitioner or any other person shall... aid demands for abortion came from people pie from Usilampatti taluk.
Under the Act, scan centres are
conducting...
any pre-natal diagnostic
belonging
iin
____
c/i
e/
- - to the Kallar community, withrequired
to maintain records of patients
techniques at a place other than a place out class distinctions. She insisted that she
•specific
abortions
only
for
for
two
years. At a scan centre in
registered under this Act.”
performed sex-j t
the poor, sometimes even six months into Usilampatti it was claimed that records are
A N ultrasound scan can help deter- the pregnancy.
maintained for one month and then
; mine the sex of the foetus from
Asked if she did not consider sex- destroyed. 1 he doctor at the scan centre
between 16 and 20 weeks of pregnancy selective abortions illegal and unethical, of course refused a request to let us look
depending on the
the parameters
parameters of
of the
the she
J replied: “There is a (demand) for abor- at the records in order to verify the broad
...............................
„ so I do it.” She added that some ; nature of tiie entries.
equipment. -For instance, with
the kinds tiohs.
of equipment generally available in nurses also performed abortions in their
jnAILURE to implement the Act has led
Usilampatti, which have relatively low- houses.
I to the unregulated mushrooming of
According
to
another
woman
doctor,
resolution monitors and do not have
scan
centres and the misuse of pre-natal
private
clinics
performed
three
or
four
trans-vaginal attachments, the sex can be
ascertained only by around the 20th week abortions> a day, against the 15-20 a diagnostic techniques to determine the
of pregnancy. With the aid of equipment month. performed at government hospi- sex of foetuses; these in turn have led to
increasing insunces offemale foeticide, in
dvdnau.v in
I*, some
ocmv scan
ov«ii centres in
..........
..............
— The
Tl— r
____ d__ _ 1__
_‘_____ clinics> was
available
Madurai
tals.
procedure
in rprivate
it is possible to ascertain the sex in the 16th hassle-free and the patient would be dis- some cases at great peril to the lives of the
week of pregnancy. But in Usilampatti, charged a few hours after the procedure, pregnant women,
Before a scan was done, no forms needed

raises larger qv^es’This
T'1 grim situation
“■

termination of pregnancy for their to be filled in and the patient’s consent
patients even between 12 and 15 weeks of was not secured because it was only an outpregnancy.
patient procedure, she said. This doctor
There is also an incidental question too conceded that the sex of the foetus was
here of the level of reliability of ultrasound disclosed to some patients. According to
scanning, that too at a fairly early stage of her, in several instances, the mothers had
pregnancy, in foetal sex determination, abandoned girl babies at the hospital and
According to a doctor in Usilampatti, the left within hours of the delivery; such
___deter
’
margin of error in the case of sex
­- babies were handed over to the receiving
mination is small. A signal from the scan­ centres run by the Indian Council for
iably leads Child Welfare.
ning professionals almost invariai

tions relating to basic socio-econoi ,ic
circumstances, pressures and ‘comp .1sions’, societal values and mental awitudestowards the girl-child, the failure
of the law enforcement system to imple­
ment relevant legislation, and ethical
.
issues concerning the medical profession.

many doctors seem to resort to medical

112

(The names ofsome persons referred to in the story
have been changed at their request.)

FRONTLINE, DECEMBER 18, 1998

*

■ COMMIU’AUSM

Fundamentalism and a flare-up
The Justice Gokulakrishnan Commission of Inquiry blames fundamentalist religious groups,
both Muslim and Hindu, for the evolution of communal tensions and the flare-up in
November-December 1997 in Coimbatore, while virtually giving a dean chit to the police.

I
I

lie but the police personnel, and also> to nary action against those erring police
avoid excessive and extensive damage to constabulary.
publicandprivateproperties. All the seven
The Commission
Commissions
’s report was tabled
in
the
Tamil
Nadu
Assembly
on November
firings
by
the
police
were,
therefore,
war
­
HpHE seven instances of police firing in
27.
The
Government
accepted
its findings
1 different parts of Coimbatore on ranted and justified.” The Commission
said
that
“
belligerent
”
Muslim
mobs
and
and
said
the
Home
Department
would act
November 30 and December 1, 1997, in
l
”
'
,
on
the
recommendation
that
disciplinary
which eight Muslims and two Hindus Al-Umma men, armed with petrol bombs,
were killed were “warranted and justified”. knives, sickles, wooden logs, swords, sick- proceedings should be launched against the
This is one of the findings of the Justice les, sticks and stones, surged ahead in the constabulary. Justice Gokulakrishnan is a
__J not heed police warnings former Judge of the Madras High Court
P.R. Gokulakrishnan Commission of places and did
Inquiry constituted to probe the murder to disperse. This forced the police to open and former Chief Justice of the Gujarat
~ constable R. ~Selvaraj
’
• on fire The police had followed the pre­ High Court.
of traffic
November 29, the “demonstrations” by scribed procedure, having issued warnings
HE report gives an account of how
policemen the next day, and other serious over the public address system before
communal
tension built up in
opening fire, the report said.
disturbances in the textile city.
Coimbatore
from
1983, after Hindu and
The Commission used strong words to
Muslim
fundamentalist
organisations
condemn the activities of certain Muslim >'T~,HE Commission blamed the “butchthe
became
active.
The
report
declares
that Al1
ery
”
of
the
“
innocent
”
Selvaraj
on
fundamentalist organisations that led up
Umma
“
is
not
only
a
fundamentalist
“
ill-feeling
”
that
Al-Umma
fundamental
­
to the violence in the short term but at the
same time traced the genesis of the Hindu- ists had against police personnel i in organisation but a terrorist movement.
Muslim communal tensions that built up Coimbatore. Hence, it could not be con- With its stated objectives, Al-Umma is
in the city since 1983 to the virulent and strued as ‘“communal”. The starting
~;point “definitely anti-national, anti-religious
vituperative speeches made by the leaders of the riots was the murder of Selvaraj, and and anti-social”, it said. The Commission
of several Hindu fundamentalist and Hindu fundamentalist groups and “unso- said Al-Umma should have been banned
hawkish organisations as well as similarly- cial” elements took advantage of the situ- as early as 1993. (The State Government
oriented Muslim organisations.
ation to “give a communal colour for banned Al-Umma and the Jihad
On November 29, three youths attacking the Muslims,” the report said, Committee within hours of the blasts in
belonging to Al-Umma, a Muslim funda- The absention from duty and the holding Coimbatore: on February 14, 1998. Alfientalist organisation, murdered Selvaraj, ofdemonstrations by policemen to mourn I Umma founder S.A. Basha and general
vhich led to a virtual revolt by policemen, the death of Selvaraj gave “free hand to ;secretary Mohammed Ansari are among
' olice firings on “ferocious” and “violent” unsocial elements which resulted in the key accused in the serial blasts case and
Muslim mobs, and large-scale arson and unchecked rioting, looting and setting fire are in jail.)
looting by Hindu fundamentalists of shops to shops,” it added.
According to the report, Coimbatore
owned by Muslims. Seven Muslims were
The Commission recommended dis- became communally hypersensitive
mtjxdered on November 30 and one Hindu ciplinary action against personnel at the from 1983. On June 10, 1983, Bharatiya
was murdered the next day. These events constabulary level for abstaining from Janata Party leader Jana Krishnamurthy
culminated in Al-Umma exploding a series duty on November 30 to show their soli- and Tirukoilur Sundaram, who criticised
of bombs in Coimbatore on February 14, darity and to pay homage to Selvaraj until Islam at a public meeting in Coimbatore,
1998. Fifty-eight persons were killed in the his body was sent to his native village. The were attacked by Basha and seven of his
explosions and the incidents that followed relevant finding said: “The constabulary, associates. Thereafter, there was a series of
them. The Justice Gokulakrishnan which has to serve the public cause, mis- incidents in which both Hindu and
^XteronMssion.is^urrentlydoold^
tp.dis,charge their dutiesMuslim fundanient^sts we.re. murdered.
that resulted in large-scale looting, rioting Besides, Hindu and Muslim businessmen
phase of trouble in Coimbatore.
The report said, “...the Commission, and arson, resulting (sic) in police firing. developed business rivalry. They came
after detailed and careful examination of Hence, barring a few, there is a lapse on into conflict during auctions and other
the evidence and the records, considers the part ofthese constabulary, who refused profit-driven activities. On the one side,
that in the exceptional circumstances that to perform their duties even after the Hindu-Muslim tension grew following
prevailed then in Coimbatore, the police direction and persuasion made by the virulent and vituperative speeches made
had to necessarily open fire in order to pre- Commissioner of Police (P. Rajendran). by speakers of the Hindu Munnani, the
vent more casualties not only to the pub- It is, therefore, necessary to take discipli- Vishwa Hindu Parishad, the Shiv Sena,

T.S. SUBRAMANIAN

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FRONTLINE, DECEMBER 18, 1998

113

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(TMMK) and the
Jihad Committee. On,the other, clashes
between the police and Al-Umma mem■bers on petty matters created ill-will
’■^•.b^tween them.
i!i: Another factor was that “there was
infiltration of Muslim fundamentalist
floups and other Muslims from nearby
Kerala State, who are dominating in vari­
ous trades in and around Kottaimedu,
Ukkadam and other areas,” the report
said. Coimbatore has a population of 15
lakh people, of which two lakhs are
Muslims. They are concentrated in
Kottaimedu, Selvapuram, Karumbukkadai and Saramedu among other places.
N the night of May 8/9, 1996, even
as the results of State Assembly and
Lok Sabha elections were coming in,
youths belonging to Al-Umma and the
TMMK demolished police checkposts
that had been erected in and around
Kottaimedu ostensibly to check the move­
ment of Muslim anti-social elements.
(According to the report, “Such check­
posts were installed after coming to know
from the pamphlets the objectives of AlUmma, which are very very dangerous to
the society.”) The youths assaulted five
guards at the checkposts, stabbing one of
them, Jothishkumar, in the stomach.
Whenever detainees under the
Terrorist and Disruptive Activities
(Prevention) Act, or TADA, (mostly
belonging to Al-Umma) were brought to
the court in Coimbatore, they raised slogans against the police, calling them
names, the report said. Whenever the
police tried to maintain law and order by
removing obstructions created by street
and platform vendors, Al-Umma men
behaved in a high-handed manner,■. The
Al-Umma activists clearly had an antagonistic attitude towards the police, the
report said.
It said, “...The followers of Al-Umma
took civil and criminal law into their own
.hands, ignoring the police, and held totaI
panchayats (kangaroo courts) by threaten­
ing people living in Kottaimedu and other
areas.” Thus, on the one hand, the hatred
and animosity between Hindus and
I
Muslims in Coimbatore, which was run­
ning high, was waiting to erupt. On the
other, the constabulary was disgruntled
i1’"’' because Al-Umma, 1 MMK and other
Muslim fundamentalist organisations were
behaving in an “unruly” manner, without
respecting the law enforcement machinery,

I

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-r?M^WBIMIIffllWIMIMnriWMWIII Ml I1,1'gaewwwafe-

■-■

In a significant and perceptive obser- College Hospital where the body
vation, the Commission pointed to factors Selvaraj
such as umemployment, illiteracy, poverty and the influx of men, women and children not only from
other districts
districts of
ofTamil
Tamil too had gathered to express fear for the
rom other
Nadu but from other States, particularly lives of the policemen).
Kerala, that have over the years compliAccording to the report, some intercated the situation in Coimbatore. Most ested parties
oarties used Selvarai
murrlA^rn
Selvaraj’s murder^.to
of the people who came in thus were iillit- spread the rumour that a Hindu com -aerate Muslims, the Commission said.
ble was murdered by Muslim fundamen­
On the night of November 29, an Al- talists. “The timing of such propagak'da
Umma follower Jahangir, who was riding infuriated the Hindu fundamentalists and
a moped, was taken to the B-l Bazaar anti-social elements who took law into
poliice station by Sub-Inspector M. 1their hands and damaged, destroyed and
Chandrasekaran to book him because he looted the properties of Muslims in varidid not carry a driving licence. While ous places in Coimbatore. The evidence
Chandrasekaran was questioning Jahangir and records make out the systematic attack
at the police station, Al-Umma general done by the Hindu fundamentalists and
secretary Mohammed Ansari came there, anti-social elements only on the Muslims
used
filthy
language
against and their properties in Coimbatore. In
Chandrasekaran and took away Jahangir. certain places, Muslim shops have been
In the meantime, rumours were afloat at
singled out from among the various other
1
Kottaimedu
that Ansari was assaulted at shops belonging to the Hindus and wer
the police
police station.
station. The
The report
report said:
said: ““AlAl- fdestroyed... Such large-scale destruction
the
Umma followers got enraged at the news, and looting ; was made easy because the
(three of them) rushed to the Ukkadam police personnel were staging demonstrapolice station area, dragged the innocent tions to mourn the death of Selvaraj,” the
police constable Selvaraj, who was on traf- report said.
ficduty, indiscriminately stabbed him and
The Commission rejected TMMK
caused his death.”
president M.H. Jawahirullah’s averment
The murder of Selvaraj was /due to the that it was the police, with the help of anti­
“ill-feeling” that Al-Umma members had social elements, that had resorted to the
towards the police because of the “various arson and looting, damaging Muslim
legal actions taken by the police”, to property, and also resorted to indiscrimi­
demonstrate their (Al-Umma members’) nate firing. The report said: “The evidence
displeasure and to teach the police a les- on record is clear, cogent and reliable, and
report
said.
Justice the witnesses have amply justified the
son,
the
Gokulakrishnan went as far as to say that opening offire.” Had the police not resort­
the culprits who killed Selvaraj had “actu- ed to firing, the anti-social elements and
ally butchered him, inflicting a number of rioters would have killed a number of
stab injuries on different parts of his body policemen and members of the public
as narrated in the post-mortem certificate.” belonging to various religious sects. The
report said: “But for the prompt actioi
HE murder came in handy for the taken by the police in the given circumHindu fundamentalist groups and stances of the case, the loss of life would
the police personnel. Policemen, below have been numerous, and the loss or damthe rank of Sub-Inspector, were agitated age to property would have exceeded sevthat one of their colleagues was brutally eral crores than at present...In the light of
murdered by Al-Umma while on duty. To the situation and circumstances I have disshow their solidarity and sympathy for cussed earlier, the firings resorted to by the
Selvaraj, they, barring a few, abstained police are warranted and justified.”
from duty until his body was sent to his
Until the time Selvaraj was murdered,
native place after post-mortem.
the police had done their best to contain
(According to informed sources, the both the anti-social elements and the fun­
strength of the Coimbatore city police is damentalist groups in Coimbatore, the
about 2,060. Of this, officers - from the Commission said. It added: “Sitting in the
Commissioner to the level of Sub­ arm chair, it is easy to pick holes against
Inspector-number 123. The rest are con- public servants and agencies. But the overstables - from head constable to Rrade 2 all assessment 1 have made ahotitrhe
— the-.
constable in different wings and Armed less work done by the police and other
Reserve Police personnel. The sources said public servants indicates that there was no
the number of policepersons who had lapse” on their part until Selvaraj was mur­
gathered at the Coimbatore Medical
dered. ■
FRONTLINE, DECEMBER 18, 1998

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<2(^c

GOVERNMENT OF TAMIL, NADU

abstract
Pre-natal - Diagnostic Techniques (Regulation and Prevention o:i
Misuse) Act 1994 - Appointment of Appropriate Authority for tl.n
State of Tamil Nadu and Constitution of Advisory Committee - Orders
issued.
HEALTH ANDFAMILY WELFAi'E DEPARTMENT

G.O.Ms.No<66

Dated:6-2-1996

1. From the Government of India7 Ministry of Health
and Family Welfare letter No.23011/49/91-PLY(Vol.X
dt. 10-11-94

2, From the Director of Medical Education letter
No.8886/H£D(l)/95 dt. 6-3-95
3. From the Government of India, Ministry of Health
and Family Welfare letter No.N.23011/59/94-PLY
dt. 29-12-95

1i

*****

ORDER:

The Government of India has par.sed
passed the Pre-natal Diagn
Diacji Stic
Techniques (Regulation and Prevention of Misuse) Act, *1994 (Cer. . ral
Act 57 of 1994) prohibiting the determination of sex. The Prc- 3 tai
D^-^gnostic Techniques (Regulation and Prevention of Misuse) Adt 1994
hasbeen notified in the Gazette of India under Section 1(3) of he
Act to come' into force on the 1st January 1996 vide publication in
the Gazette of India Extraordinary part II Section 1 dated 20-9-94
as Act No. 57 of 1994.
On tlic advise of the Government of Indi-',
the State Government have published the said Act in part IV
Section 4 of the Tamil Nadu Government Gazette, dated the 17th i ’•y
1995 and now the State Government have proposed to appoint OneAppropriate Authority for the State and to constitute an Adviso: y
Committee to assist andadvise the Appropriate Authority in disci urge
of its functions and also one of the official member in Advisorv
Committee to be its Chairman.

2. The following notification will be published in the
Tamil Nadu Government Gazette, Extraordinary, dated the gth
February 1996.
NOTIFICATION
In exercise of the powers conferred by sub-section (2) of
section 17 of the Pre-natal Diagnostic Techniques (Regulation ai .1
Prevention of Misuse) Act, 1994 (Central Act 57 of 1994),
the Governor of Tamil Nadu hereby appointsthe Director of Medio 1
and Rural Health Services as Appropriate Authority for•the whole
of the State of Tamil Nadu for 'the purposes of the said Act ,
p. 1,0,

2

NOTIFICATION II
In exercise of the powers conferred by sub-sections (5) ano
(6) of section 17 of the Pre-natal Diagnostic Techniques (Regulc'.ion
and Prevention ofMisuse) Act, 1994 (Central /let 57 of 1994), to ^id
and advise the Appropriate Authority appointed under sub-section (2)
of the said section 17 of the saidAct in the discharge of its
functions, the Govcrnorof Tamil Nadu hereby constitutes an
Advisory Committee consisting of the following members, namely.(a) The Director and Superintendent, Institute of Obstetrics
and Gynaecology and Government Hospital for Women and
Children, Madras-8. (Chairman)

(b) The Director and Superintendent, Institute of Child Health
and Hospital for Children, Egmorc, Madras-8,
(c) The Professor of Genetics, Institute of Child Health and
Hospital for Children, Madras-8,

(d) The Government Pleaderz High Courty Madras,

(e) The Deputy Director, Information, Education and Communication,
Office of the Director of Familv Welfare, Madras-6.
(f) Dr, jaya Sreedar, 6, Nungambakkam High Road, Madras-34.

(g) ('hut) Nandini Rajendran, President, Social Welfare Beard,
11, jagadeeswaran Street, T.Nagar, Madras—17.
I«,

(h) Tint .Man ju la Ganosh Dabu, Advocate, 2725, Old Y Block,
New A.M., 7th Str^Ht, 12th Main Reid, Anna Nagar, Madras-4;.

(BY ORDER OF THE GOVERNOR)

R. POCRNALINGAM
SECRETARY TO GOVERNMENT
To
The Director of Stationery and Printing, Madras-2.
(for publication in the Tamil Nadu Government Gazette)
The Director of Medical Education, Madras-5.
The Director of Medical and Rural Health Services,'Madras-6.
The Director uf public Health and preventive Medicine, Madras-6.
The Director of Family Welfare-, Madras-6.
The Government of India, Ministry of Health and Family Welfare,
New Delhi-110 Oil.
The Director and Superintendent, Institute of Obstetrics and
Gynaecology and Government cf Hospital- for Women and Children,
Madras-8,
The Works. Manager, Government Press, M3dras-79.
p. L , O .
(for publication in the Tamil Nadu Govt. Gazette)

.<' •€

’-.w- «ai.as»s»NH*e- <•

3

To
The Director and Superintendent, Institute of Child Health and
Hospital for Children, Egmore, Madras-S.
The Professor of Genetics, Institute of Child Health and Hospital
for Children, Madras-8.
The Government Pleader,tHigh Court, Madras.
The Deputy Director, Information, Education and Communication,
Office of the Director of Family Welfare, Madras-6.
Dr. jaya Sreedar, 6, Nungambakkam High [:^ad, Madras-34.
(Tmt.) Nandini Rajendran, President, Social Welfare Board,
11, jagadeeswaran Street, T.Nagar, Madras-17.
Tmt. Manjula Ganesh Babu, Advocate, 2725, Old Y Block, New A.M.,
7th Street, 12th Main Road, Anna Nagar, Madras-40.
The Director of Medical and Rural Health Services, Madras-6.
Copy to:

All District Collectors.
Senior Personal Assistant to Minister for Health, Madras-9.
The Law Department, Madras-9.
v i/6.2

// Forwarded by Order //

(R.SRINIVASAN)
SECTION OFFICER

r.t •ay-.-.K* •'«

*t»i ■?*4Za«s*i•./■*'

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Section 1: MICRO LEVLL STUDIES

FEMALE INFANTICIDE: PHILOSOPHY,
PERSPECTIVE AND CONCERN OF SIRD
M. Jeeva, Gandhimathi and Phavalam
Background

Indian Context

Violence is a state- of exploitation,
discrimination, upholding of unequal
economic and social structures, the creation
of an atmosphere of terror, threat or reprisal
and lorms of religio-cultural and political
violence.1 It can be perpetrated by those in
power against the powerless or by the
powerless in retaliation against coercion by
lhers. Gender violence is deeply entrenched
in almost all cultures. Its forms are: different,
unequal and discriminatory treatment by the
family as well as the state, such as
discrimination in health care, education, access
to lood. right to resources, gender division of
labour, gender discriminatory values against
women, etc. Extreme forms of gender
discrimination are female infanticide and
foeticide, and the selection of sex before
conception.

1 hough we lind mention of prayers being said
lor the birth of a son. we do not come across
any reference to eliminating daughters at birth
in the ancient Vedic period. According to the
Alharva Veda, The birth of a girl, grant
elsewhere; here, grant a boy’. Gender
discrimination was strongly dictated in Manu,
according to which a female is under the
custody of males from womb to tomb.

Female infanticide and foeticide are not unique
to India - they are prevalent almost globally.
Studies show that infanticide and foeticide
were prevalent among Arabian tribes, the
Mmomani Indians of Brazil and in ancient
Rome. Exposing the female was a popular way
I killing, the decision for which was taken
entirely by the male members.2

Female infanticide was quite common in precoinmunist China, though it has now been
replaced by foeticide.- Among the South
Asian diaspora in Britain, USA and Canada,
abortion of female foetuses has been
prevalent for over 15 years. Among the
immigrant Punjabi community in Canada,
occasional cases of female infanticide arc
reported every few-years.
SEARCH BULLETIN July - September 1998

However, it was the British who first
documented the practice of female infanticide
in India. In some parts of Rajasthan and
Punjab, female infanticide was practised in
the early 19th century, and its incidence was
high among the Jadeja Rajputs of Saurashtra
in 1805. There were no daughters in a village
in eastern Uttar Pradesh during the same
period.4 Thousands of foetuses are being
killed every year in Haryana, Uttar Pradesh
and Himachal Pradesh to ensure that the
desire for a male child is fulfilled.5 Though
the practice is of recent origin among the
Bhati community in Juisalmer, their sex ratio
is one of the lowest in the world
(approximately 550)? Contemporary cases
ol female infanticide can be traced in parts of
western Gujarat, Bihar and Madhya Pradesh.
In Tamil Nadu, it is reported in the districts
of Salem, Dharmapuri and Madurai.

The census data is the standard base used to
study the existence of the practice in India.
The sex ratio of children in the age group of 04 is taken to be an accurate indicator of the
prevalence of such practice. (See Table 1 in
the article ‘Female Infanticide in Tamil Nadu’
by Sheela Rani Chunkath and V.B. Alhreya,
9

for juvenile population of the stale and
districts.)

According to census data, the child sex ratio
was favourable to girls in Madurai district till
1951, after which it began to decline sharply,
particularly after 1981. In 10 of the 21 blocks
in Madurai district, of which Usilampatti
block is one, the sex ratio was below 900.

Status of Women in Kallar
Community .
As the heinous practice of infanticide is
widely prevalent among the Kallar
community, it is necessary to understand the
community from a historical perspective. The
Kallars are the dominant community in the
Usilampatti region. They are militant in nature
and indulge in anti-establishment activities for
their livelihood. They were branded as criminal
tribes by the British Raj and a special act was
enacted to control their behaviour. During
this period, the male members of the
community were ordered to spend their nights
in the police station. Women in this
community were assertive. Since the men had
to be away from their families for long periods
of time for professional reasons, the
production role was played by women, who
supported the family in their men’s absence.

When the Kallars turned to agriculture for
their livelihood, they practised sustenance
agriculture. But seed, water and cattle
management were under the control of women,
who played powerful productive and
reproductive roles. Kinship marriage was the
norm, with bride price being paid by men.
Dowry was unheard of. But the expenses
related to social functions prevailed. Thus
the status of women was relatively better
before 1950.
Keeping this perspective in mind, SIRD
conducted a micro-level study for the purpose
of this paper: It is generally assumed that
female infanticide is a dowry-related crime. To
verify the validity of this statement, we first
had to find answers to several questions: how

the practice took root, which agents nurtured
the practice, how it spread to other
communities, why it was adopted by some
communities, why some communities are
immune to it, etc.

Methodology
Different communities in Usilampatti region,
in which this practice is prevalent, were
interviewed. A sample survey was conducted
in Usilai. 120 women respondents were
selected. The sampling was purposive and
carefully selected to meet the purpose of the
study. The caste-wise break up of respondents
is: Kallars - 57, Dalits - 39 and Backward Castes
-24.
The micro-study gave special emphasis to
change-factors' such as the impact of
structural adjustment programmes, the
marriage system, dowry, familial violence and
cultural violence. However, discussions were
also facilitated with academics, social
researchers and other NGOs working on the
same issue. The following paragraphs
elucidate the outcome of the micro-level
analysis with the primary stakeholders and the
insights gained from deliberations at different
levels with different people.

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Violence Against Women before
Structural Adjustment Programmes
The green revolution gained momentum after
1950 and the Vaigai dam was constructed in
1958. Part of the land in Usilai region was
covered by the Vaigai irrigation system, but
the rest remained ram-fed. Land under the
irrigation system generally gets water supply
for six months. This system combined with
electricity led to a boom in agricultural
production. The wetland farmers shifted to
cash crop cultivation. The dryland farmers
had to take a gamble on nature. This gave
rise to wide economic disparities between the
Kallars of the rain-fed area and those of the
wetland area. The economic disparity
disrupted the traditional family system and

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SEARCH BULLETIN July - September 1998

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marriage bonds. Economic prosperity
combined with the obsessive hold of the
"sanskritisation process’ encouraged the
Kallars of the wetland area to spend more
money on marriages. Bride price was
replaced by the dowry system. Kinship
marriage lost its value. Giving and receiving
large dowries became a status symbol. To
maintain the status quo, the dryland Kallars
also adopted the dowry system. ‘More
daughters means more expenses’ thus
became the dictum of the Kallar community.
An intense anti-daughter attitude developed.
Thus the incidence of female infanticide
increased in the recent decades.

Violence Against Women after
Structural Adjustment Programmes
rhe impact of SAP has brought new power to
Kallar community. The shift from investment
capital to financial capital has made several
families take up money-lending in a big way.
Many of them have financial institutions,
which make it easy to multiply money. So land
accumulation and capital accumulation set in.
The Kallars soon became the economic mafia;
the political nexus between this newly
emerging class within the Kallar community
and the ruling class gave rise to new forms of
violence which they used to protect their
newly gained status and power. . The
criminalisation of politics and the
consolidation of this new class with the
accumulated power dictated changes in both
the private and public domain. In other words,
it worked against the status of women. The
preference for a male child is further reinforced
as this new power is vested in and exercised
by the male.

The Kallars carry the traits of self-infliction
to prove their loyalty. Women have to be viewed
in this context and they are forced to kill their
unwanted heirs - the girl children - in order
to prove their loyalty to their husband and
family. It is to be noted that the majority of
SEARCH BULLETIN July - September 1998

the Kallar families are wage labourer^ and
they adhere to this practice as it has the
community sanction.
With the coming of SAP, dalits have been
denied their usufructural rights over common
property resources as well as already existing
employment avenues. They are thus
increasingly becoming powerless. The
women face class, caste and gender
oppression. Sexual violence is used by the
dominant classes as a tool to exercise control
and to perpetuate caste hierarchy. Moreover,
since male children are now entering the work­
force, boys are preferred in the family. This
dire situation of poverty and the anti-girl
attitude result in female infanticide. But the
practice among dalits in other geographical
areas is yet to be explored.

Violence with regard to Women’s
Labour
With the onset of green revolution, there was
a shift from subsistence to cash crops. Due to
the introduction of new, hybrid seeds, artificial
fertilisers, new cultivation technology,
electrification, mechanisation, credit system,
market system etc., the upgraded farm system
marginalised the women from agricultural
activities. Their production role thus started
to diminish. Abundance of labour and scarcity
of work led to a reduction in wages. This is
compounded by the problem of wage
discrimination. Most of the work taken up by
women is unorganised, and with their role in
production highly reduced, men have become
even more powerful. The women work-force
is also subjected to sexual violence in the
work-place. As most of the dalits are landless
and have to depend on other castes for their
survival needs, they silently bear the sexual
violence inflicted on them.
Female infanticide is also reported to have
been adopted by other backward classes in
this region. One can assume that this is due
to the spiralling effect.
11

Changing Dowry System
While the procedures may vary, the dowry
system prevails in all communities. Marriage
expenses vary depending on the community
and the economic condition of the family. Of
the 57 Kallar respondents, 24 shared that they
were harassed by their partners to bring more
dowry. Of the 63 respondents comprising dalits
and others, 19 claimed to be similarly harassed.
Name of the
Dowry
Practice of
Community Harassment Foeticide/
Infanticide

yes

no

yes

no

Kallar

24

33

48

9

Dalit

12

27

27

12

Other castes

7

17

4

20

Dowry is generally pronounced as a reason
for infanticide. While the table shows that
there is a connection between the female
infanticide and the institution of dowry or
marriage payments, it also reveals that all the
respondents who indulged in infanticide and
foeticide were not necessarily the victims of
dowry harassment. Among the 9 respondents
of the Kallar community who did not practice
female infanticide/foeticide, six had fertility
lower than average and two were sterilised
with two children of both sexes and one
sterilised with two female children.

The study therefore does not support the
statement that female infanticide is only a
dowry-related crime.

Familial Violence
Physical
The harassment of women, particularly in the
context of marriage, is a continuing social evil.
Except for a negligible few, almost all the
women admitted to being beaten. Some of
them were beaten so brutally that they had to
be treated in hospital. Battering is thus an

/2

integral part of the marital relationship. The
husbands of at least half the respondents are
alcoholics and 40 per cent of the remaining
are occasional drinkers. The major portion of
the husbands’ income is being spent on
drinking. Most of the women said that they
were beaten when their husbands were
intoxicated. Alcoholism is increasingly
becoming a tool to perpetuate violence against
women and to institutionalise patriarchy.
Battering is also committed by men belonging
to the upper castes and classes. So, regardless
of class and caste background, women find
no way to escape from such violence. Many
women regret being born as women. Most
said that they had learned to live with the
battering, even though they suffered acutely.
Only four shared that they retaliated and beat
back their husbands.

Constantly subjected to physical abuse,
women lose their sense of dignity in the face
of violence, shame and humiliation. Their
identities have been completely submerged.
The values attached to the family system
support and justify domestic violence and
such victims would be further condemned if
they dared to oppose this violence. Unable to
bear these hardships, a few of the respondents
had opted for separation. But they were
forced to return to the conjugal family due to
lack of parental support.
Psychological

Psychological pain followed by sexual
violence is the next hardship women face in
the marital relationship. There is also suffering
due to social separation because the above
hardships - dowry harassment, ridicule,
dehumanising treatment, caustic remarks,
verbal abuse - all these contribute to the
psychological pain inflicted on women. They
realise that separation will not cure their
psychological bruises, so they learn to live
with the pain. Psychological violence leaves
no visible bruise but it is as debilitating as
physical assault.

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Sexual Violence in the Conjugal
Relationship
The respondents were reluctant to address the
issue of sexual violence in the conjugal
relationship due to fear of social censure. Of
the 120 respondents, only 18 said that their
sexual relationship was normal, that their
feelings were being respected and there was
compatibility. Coercion, compulsion, abnormal
behaviour and violence characterised the
conjugal relationships of the rest of the
respondents. Physical and emotional
conditions are meaningless before the sexual
behaviour of the partners - they shared. Sexual
behaviour under intoxication is hateful. The
problem becomes worse if the husband has
some other affair. It has been proved that extra­
marital and pre-marital relationships of the
husband are highly correlated with his sexual
ehaviour in the family. Of the 120
respondents, 52 say that their partners have
extra-marital relationships.

Almost all said that they^had no one to confide
their sufferings to. This is hardly a topic to be
discussed openly, they said. They therefore
suppress all feelings associated with sexual
abuse and the related physical and emotional
abuse within themselves and all these
suppressed feelings are expressed in different
forms.

Emotional Responses of the Women
to the Violence
he respondents were tormented with
profound feelings of remorse, depression,
disgust, frustration, rage, guilt, low selfesteem, worry, hatred, despair, helplessness
and hopelessness. Shouting in anger, and
withdrawal were the typical emotional
responses, which in extreme form led to
suicidal thoughts and suicide attempts. It was
shocking to note that 63 respondents had
suicidal feelings while 40 had actually
attempted suicide.

SEARCH BULLETIN July ■ September 1998

Reasons for the Suffering
The respondents ascribed the suffering to the
following reasons, listed in the order they
were mentioned: being a woman; giving birth
to more female children; alcoholic behaviour
of husband; suspicious tendency of the
husband; failure to give birth to male children;
economic condition. In their perception, being
born as a woman is the main cause for all their
sufferings. The ability or inability to produce
sons has important repercussions on the
woman’s life.

Violence in the Community
Most of the respondents revealed that sexual
violence or the threat of sexual violence
outside the family is used by men to control
the mobility and sexuality of women and
young girls. In the absence of parents, the
girls are no longer safe, even at home. Most
of the respondents said that they were not
allowed to move freely in the village when they
were young. Even visiting each others was
uncommon. In some families there were severe
restrictions. Autonomy and initiative were not
encouraged. This growing cultural
devastation combined with the continuous
threat of violence sanctioned by societal
norms have had a negative impact on mindset
and behaviour of individuals. In turn, they
also restrict the mobility of their daughters
because they feel that the streets are not safe.
However, in keeping with their married status,
the respondents do have restricted and
regulated freedom in domestic and outside
spheres. Being widows or mothers of a large
number of female children also places
restrictions on mobility.
Though mothers desire to educate their
daughters, education is denied to them after
puberty because of the threat of violence.
Given their own life experiences as a result of
early marriage, most respondents would prefer
their daughters to get married after the age

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of 20. However, the threat of violence forces
parents to marry off their daughters early. On
the other hand, economic compulsions in the
family force young girls to go out and work
despite the threat of violence. Almost all the
women said that utmost care is necessary to
protect the girl children because of the
atmosphere of increasing insecurity.

The fear of violence, which restricts women’s
mobility and sexuality is a very powerful
weapon of subjugation, had been deeply
internalised by the women.

Real Perpetrators of Female
Infanticide / Foeticide
The following table shows the details of
persons who are the perpetrators:

Same of die Husband Husband & Self Other
Communit}
Mother-inlaw
17

4

Dalit
10
Other castes 3

2
1

Kallar

5

The table clearly shows that infanticide is
being practised at the instigation of the
husband or mother-in-law. Others employed
aged persons and ayahs to kill the child.

Attitude of Women towards Female
Infanticide
An analysis of the feelings and attitudes of
the respondents reveals that women are
pressured by the family to commit this act.
They experience depression and grief, the
degree and forms of which vary from individual
to individual.

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Attitude towards Sex-preference of
Child

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All respondents wished to have at least one
girl child as they felt that girls are more
emotionally supportive and helpful
throughout their life. Their resistance to
daughters sets in when they fail to produce a
1 4

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son or when they have an oppressive life
experience.

Perspective of SIRD
SIRD perceives female infanticide and foeticide
as extreme forms of gender violence. We use
the term gender as an analytical category and
our political position is that the unequal power
relation between men and women, which is
further aggravated by the class-caste and
ethnic hierarchies, form the base of this
systemic violence. They also constitute
themes around which women’s oppression
and violence against women have been
interpreted.

Political Economy
At the international level, the racist bias of
population policy and the commercialisatiorr
of health care and medicine, the uncontrollable
consumerist cult reinforced by the globaf
market and the commercialisation of human
relations due to a decline in cultural values^ ;
the hegemony of imperialist nations on
developing countries in terms of sharing
world resources and power, turns women into
easily disposable commodities. Thus
objectification, domestication, and
commodification of women by the market
economy endangers the lives of the women.
Being a patriarchal institution, the family
socialises its members to accept hierarchical
relations expressed in unequal division of
labour between the sexes and power over the
allocation of resources.
The community (i.e. social, economic, religious
and cultural institutions) provides the
mechanisms for perpetuating male control over
women’s sexuality, mobility and labour. The
state as a patriarchal unit legitimises the
proprietary rights of men over women,
providing a legal basis to the family and
community to perpetuate these relations. The
state does this through the enactment of
discriminatory laws and policies
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c It is very important to contextualise the family,
community and state in the ongoing
recolonisation process. In India, the shift
from subsistence economy to the imperialist
mode of production to suit the demands of the
global market resulted in feminisation of
poverty and pushed women to experience
newer forms of violence. As the ruling class
has shifted their interest from domestic
capital to international capital, there is a
growing lawlessness bn the part of the state.
While existing laws are beingliberalised/
diluted, we see the emergence of new,
repressive laws controlling economic,
political and civil rights. Simultaneously,
the state is co-opted by the market forces in
exercising control over women’s labour and
sexuality.

whereas the men could have relationships with
many women. This double standard of morality
has resulted in both physical and mental
incompatibility between the couple leading to
more divorces, separations and desertion.

Though lower caste and lower class women
claim a greater degree of independence with
regard to choosing their men, they are more
subject to social violence (social patriarchy).
Their very independence defines them as
sexually accessible and hence vulnerable to
violence by upper caste/class. They often
resort to female infanticide/foeticide because
of their vulnerable status.

Concern
•

Unless women’s condition and position in
the family is strengthened, they will remain
powerless. Power is concentrated in men
because of their ownership and control of
economic resources. Thus, to improve the
status of women, SIRD is working to
facilitate women sangams which address
issues concerning both practical gender
needs and strategic gender interests.
Women are facilitated to actively
participate in the Panchayat Raj system,
w'hich is another strategic intervention by
SIRD for the political empowerment of
women.

•

Training and organising efforts to enable
women undertake issue-based struggles
and campaigns to achieve gender justice.
SIRD also facilitates the networking of
these women’s organisations with other
like-minded networks at both micro and
macro level.

•

Economic empowerment of women by
implementing many developmental
programmes.

•

As a step towards ideological
empowerment, training on gender analysis
and sensitisation is extended to sangam
women, men and other allied forces like
student communities and academicians.

In a society wfrere women are already denied
property rights, privatisation of resources will
worsen Ore condition of women, putting her
in a more vulnerable position and reinforcing
. the anti-women attitude. The media advocacy
by the global markets objectify and commodify
a woman’s body and she experiences even
more violence outside the family and at the
work-place. All these factors reinforce and
strengthen the anti-women attitude.

In the early days, the women of the Kallar
community often claimed a greater degree of
independence in choosing their marital
partners. The marriage system was so liberal
that mutual consent to live together ended up
in marriage. It had societal sanction. Divorce
was much easier, and the divorced woman had
the option to choose another partner. As she
had access to maternal property, she faced
fewer problems and could even take care of
the children by a previous marriage.
With the introduction of the Sanskritisation

process and Hindu ideology, this marriage
system changed (pathi viradha and
submission). It is ironical that women’s
sexuality was controlled and her right to live
with a person was limited to one person

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Informal discussions with adolescent girls
reveal that they too have a preference for
boys but do not intend to kill their female
infants. They are aware of the constraints
under which they live. They said that they
would limit the size of their family, which
should ideally be composed of two
children. They said that they would not
mind even if both are girls. They felt that
education and economic independence
would go a long way in strengthening their
position. Thus their reaction to the birth
of a girl child is not adverse. SIRD intends
to build the next generation with new
values, social skills and behavioural
patterns to challenge the violence and thus
improve their condition and position. As
a proactive strategy, adolescent girls and
boys are being organised and given gender
awareness training. Skill training is also
being planned for them.

Alcoholism among men triggers off
physical, psychological, sexual, class,
caste and community violence. Anti-liquor
campaigning was thus adopted as a
programme by SIRD, and it is an integral
part of the campaign against violence on
women. The campaign against violence
on women actively addresses every issue
that affects women.
Documenting cases of domestic violence
and providing services like counselling,
legal aid and protection to the victims in
their short stay home.

o

o

As a proactive strategy, a monitoring wing
in each village comprising members of the
community is being constituted to directly
monitor pregnant women and children in
the age group of 0-6, and to look after their
health care needs etc.

It is involved in legislatifve^advocacy and
lobbying to change discriminatory
personal laws. As a step towards this, it is
planning to bring out ajstatus report of
Kallar and dalit women.
|

•

SIRD is part of a wider network at the
regional level and participates in national
level campaigns and networks which work
for gender just laws.

Legal Aspects of Female
Infanticide
Most NGOs and activists associated
with the fight against female infanticide
have stressed the need for a change in
the interpretation of the law. The present
situation reveals that the state has failed
to function and is therefore unable to
protect its citizens.
For example, dowry deaths, however
cold-blooded, are considered to be
social crimes and not murder, and the
law can only sentence the offender for a.
maximum of seven years in prison. Even
when there have been convictions, they
have hardly served as deterrents to
others as the crime has not shown any
signs of declining.

i As regards NGO attempts to deal with
social issues through the law, not very
much has been accomplished. Often,
only appeals have been made.
Similarly, in trying to convict those who
run sex-determination clinics, the legal
system cannot help NGOs very much.
It is very difficult to prove that the test
was conducted in order to determine the .
sex of the foetus, as clinics do several
tests on pregnant women for various
reasons. Although there is a law, there
are too many loopholes in it for it to be
implemented as a case of professional
misconduct, and strike the doctor off the
registers and confiscate his licence to
practice.

We should understand that criminal law
is repressive against economically
backward people. NGOs can conduct
public hearings, hold people’s courts
and publicise their actions widely.

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Source: Ms M. Kavitha, Consumer
Action Group, Chennai - CRHSE
Seminar Report 1995.

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Legal Assistance for Victims of
Repression by the Government
•

V

In the recent judgment in the case of female
infanticide (Karuppayee vs State, through
Inspector of Police, Usilampatti police
station in Cr.No.49/94, in the court of the
Second Additional District and Sessions
Judge, Madurai, dated 24 December, 1996,
S.C.No. 173/95), only the mother of the
deceased two-day old infant was
convicted and given life imprisonment
under 302 IPC. Though the father of the
deceased infant was also accused, he was
acquitted since it was contended that the
infant was under the care and protection
of the mother; the two-day old infant could
be handled only by the infant’s mother and
no other person could have had access to
her. The judgment reveals the gender bias
against women, and is another instance of
the atrocities committed by the state on
women. The judgement reflects the values
of a patriarchal system. SIRD has appealed
against this judgement. The state is now
in the process of drafting a new bill
prohibiting female infanticide. The
Campaign Against Female Infanticide
launched by different women networks in
Tamil Nadu, in which SIRD has played a
key role, are seriously involved in
advocacy work. They intend to file a
Public Interest Litigation (PIL) against the
new bill if it is favourable to women.

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All family members who are partners in the
act of female infanticide, should be
brought before the law and be seriously
punished. Husbands and mothers-in-law
are the partners in most of the killings.
Would punishing the men improve the
position and condition of women? This
question is still being debated in our
network. If the perspective is to change
the unequal gender-relations and gender
hierarchy, a punitive attitude would further
weaken the position and condition of
women. SIRD fears that it would reinforce
the anti-women attitude rather than dilute it.

References
1. Karlekar, Malavika : ‘Domestic Violence’,
Economic and Political Weekly, 4 July, 1998.
2. Mitra, Amit: Female Foeticide - A primitive
trend practised the world over ‘, Down to Earth,
31 October, 1993.
3. Chowdhry, D. Paul : ‘Girl Child: Victim of
Gender Bias , Girl Child in India, Ashish
Publishing House. New Delhi.
4. Panigrahi, Lalita : British Social Policy and
Female Infanticide in India, 1972.
5. Report of Chandigarh-based Centre for
Research in Rural and Industrial Development.

6. Venkat Ramani, S.H. : ‘Born to Die,’ India
Today, 15 June, 1986.

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Group II : Legal Group
Dr. .Anita Rai, (DCP North District, Delhi) Chairman of the group emphasized that
doctors and the public should be made aware of the practical as well as technical aspects
of laws pertaining to female foeticide infanticide, fhere are many who believe that laws
do not really do anything to bring about social change or development as reflected by the
recent monograph from the Centre for the Child and the Law, NLSUI Bangalore.
However the state has a moral obligation to enact just, equitable, and gender-sensitive
laws.

(

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Dr. Sharda Jain said that the first sex determination clinic in the private sector in India was
set up in Amritsar in 1979. For fifteen years, till the Central Government enacted a law
forbidding prenatal sex determination! 1994), there was an explosion of clinics and
widespread use of these tests, and large scale abortion of female foetuses. Neither the
abortions nor the sex determination tests have abated. But at least there is now a legal basis
for questioning such acts.
ILe absence of any law forbidding this heinous crime resulted in a dramatic reduction of
under-five sex ratio from 925 to 874 girls/1000 boys over the intercensus period 1981 1991 .In isolated surveys spread in villages of Rajasthan, Bihar and Madhya Pradesh the
under - five sex ratio has touched 500 girls per 1000 boys. Once such crimes have received
implicit social acceptance over a long time, it is difficult to regulate them by laws alone.
I lowever, the role of the law can never be undermined. In this light, the group discussed
the following:
1. What are the various laws governing medical termination of pregnancies and sex
selection?
2. What are the weakness and loopholes?
3. What are the changes that need to be brought in the legal framework to strengthen the
laws for prevention of this crime?
4. What are some of the obstacles in the implementation of the laws?
5. How should the laws be monitored?
6. How much does it cost to fight a court case?
7. What preemptive and appropriate interpretations of law are needed*?

Hc P

1. Laws governing medical termination of pregnancy and sex selection
Female Foeticide
Pre-natal Diagnostic Techniques (Regulation and Prevention of Misuse) Act 1994
Came into force from 1st January 1996.
•-----------------------

Main provisions of the PNDT Act :
1. 1Prohibition of the misuse of pre-natal diagnostic techniques for determination of sex of ;
the foetus leading to female foeticide.
2. Prohibition of advertisement of pre-natal diagnostic techniques for detection or
determination of sex.
3. Permission and regulation of the use of pre-natal diagnostic techniques for the purpose |
of specific genetic abnormalities or disorders.
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'|4. Permitting the use of such techniques only under certain conditions by registered
institutions.
5- Punishment for violation of the provisions of the Act.
Under no circumstances would these techniques be allowed to determine the sex of the I
foetus. (S.6) (This includes ultrasonography )
!7- No person conducting pre-natal diagnostic procedure (under S.4) shall communicate to
the pregnant women concerned or her relatives the sex of the foetus by words, signs or
in any other manner is liable to be punished.

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An appropriate authority (AA) shall take note of violations either by itself or by a
private company/ person. After 30 days ’ notice to Appropriate Authority, it may
cancel registration, search, seize premises etc. (??)
Violations punishable with 3 y'ears imprisonment andzor Rs. 10,000/- fine.

fhe group discussed the Act in detail and made following recommendations.
1. Ihiblicity : It was emphasized that publicity is required for :
• Prenatal Diagnostic Techniques Act (1994). among doctors and public at large .
• ‘ Appropriate Authority’is to be constituted without delay at all district levels and given
due publicity, so that the people know whom to approach.
• List of registered institutions for genetic testing to be notified by IMA regularly. I his
will be a deterrant to unregistered institutions.

2. Guidelines for formation of an Advisory Body which should consist of :
• a legal expert
• a medical expert
• a social expert

3. Amendments :
• "Appropriate Authority (A A) or its Nominee/ Nominees" instead of "First Appropriate
Authority'*
• Should include ban on prenatal sex selection by any method offered in a clinic set up

•

The time period of complaint to the Appropriate Authority should be reduced to one
week instead of 30 days

4. The “grey areas” of Pre-natal Diagnostic Techniques Act 1994
Prof. Moolchand Sharma and Dr. Anita Rai highlighted the grey areas of the PNDT Act.
1994
• Complaint : Permit third party complaint but with safeguards.
• Evidence : (Jnus of proof to be shilled to doctors and the family of the victim.

5. The groups strongly felt that there is urgent need to form a nucleus of legal and medical
experts who would examine the existing laws clause by clause, and then draft a legal
document to put up to the media and the Government.
Medical Termination of Pregnancy Act, 19^1

i Main provisions of the Act :
'in order to safeguard the health of the pregnant women, abortion allowed in certain
I circumstances
1. Risk to life of the woman
2. Grave injury to her physical or mental health. Includes:
a) Failure of contraception for married women.
b) Pregnancy by rape
3. Substantial risk of the child being bom abnormal or handicapped

If pregnancy is less than 12 weeks, the registered medical practioner must in good f aith
believe that it involves one of the above circumstances.
• If 12-20 weeks , concurrence of 2 medical practioners is required.
'• If above 20 weeks, it can be done only to save the life of the woman.
i • Abortions
- Unless done in good faith to save the life of the mother, are punishable with 7 years
i imprisonment.
i - If without real consent of the woman, with 10 years imprisonment.
- If the woman dies while inducing abortion, with 10 years imprisonment.
i* Doing an act intended to prevent a child being born alive is punishable with 10 years
' imprisonment.
• Causing the death of a quick’ (4- 5 months) unborn child is punishable with 10 years

J imprisonment.
• MTP only in government approved places unless required to save the life of the woman.

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Dr. Sangeeta Gupta and Dr. Neelam Singh highlighted various aspects of MTP Act and
their misuse and abuse and made the following recommendations.
Registration of abortion beyond 12 weeks to be universalised.
Sex of the foetus for all second trimester abortions to be documented clearly.
Specific cause of termination to be mentioned.

•
•
•
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Ms. Diva Kapoor and Ms. Andal Radhakrishnan spoke about the existing laws on female
foeticide. A summary' is given below :
•
•

Female foeticide is illegal under the IPC
Both parties are punishable upto 10 years

1 • Who should be punished ?
The mother ?
- She has no choice but to succumb to family pressure
- Plays no role in decision making
- Is following “superior orders”
However there is no basis for excusing her under criminal legal theory
The father/relatives ?
- For abetment of the crime
-1 Jable but rarefy punished

Female Infanticide
Ms. Sharukh Alam spoke about laws relating to female infanticide which are summarised
as follows:

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Indian Penal Code
S 299 & 300 - Female infanticide treated as culpable homicide'murder
S 315 - Punishes acts done before birth with the intention of causing death at birth.
Punishment -10 years
S 317 - Provides for punishment for exposing/abandoning child so that it involves
physical risk to child. Punishment -7 years or fine
S 31X - Provides against concealment ol birth and death of a child . Punishment - 2
years or fine.

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•
•
•
•

Infanticide : Analysis of the law
Female infanticide amounts to murder
Societal consent for female infanticide is obvious in India
Since method of killing the infant is often indirect, it is impossible to prove homicide
It is important to note that the liability falls on person who performs the actual killing.
In cases of female infanticide, the mother is held responsible which is unjust.

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The Special Act of 1870 on Infanticide
Phis Bill streamlined the measures the government could take to check the practice of
female infanticide . It suggested
1. An enlarged police force
2. Increased surveillance of community
3. Thorough census
4. Restrictions on marriage expenses

Measures to enforce the Act were provided within the Act and included
1. Periodic census
2. Monitoring of pregnant women by village authorities
3. Meticulous registration of births, and inquests if the child died within a week.
4. Local government was given the legal authority to enforce the measures, and violation
of any of the provisions was punishable by 6 months imprisonment and fine.
5. It made midwives/ chowkidaars and a range of village officials and functionaries
responsible and therefore discouraged a considerable number of people from abetting the
crime.

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The laws for the child as they exist today
• Article 6 of the Convention on the Rights of the Child provides that the state shall
recognise that every child has the inherent right to life. It also casts the duty upon the state [
to ensure to the maximum extent possible the survival and development of the child.
• The Constitution of India (Art. 21) provides that every’ person shall have the right to
i life. This would include an infant as well.

Thus the Convention along with the Constitution, casts the duty upon the state to take all
measures to protect the life of the girl child.

Recommendations
•
•
•
•

Definition and penal sections are available, but the criminal procedure and law of
evidence need a shift.
On the presumption of crime being there, onus of proof should be shifted to the
father and his family , in case a female infant dies in the family.
Make inquest compulsory in all cases of female infant death
Account for acts of omission as well as commission resulting in death.

Additional Suggestions
• Amend existing laws that have gender bias so that the myth of male superiority can be
exploded.
• Pro-active investigation and penalty on the basis of preponderance of evidence should
be done, rather than proof beyond reasonable doubt.

In conclusion. Dr. .Anita Rai said existing laws require modification for them to be effective
and a debate of legal luminaries is needed urgently. IMA should pressurise the Control
Advisory Body to take preliminary steps like constitution of Appropriate Authority at all
district levels

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Joint Recommendations

FoGTJ

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In the valedictory session, the reports ol all the working groups were thrown open to
discussion, which was coordinated bv ITr.V.C. Patel
(>n analysis, every' group had quite a few overlapping suggestions. /Kfter an intense brain­
storming session, joint recommendations were presented for future course of action. The
final suggestions are as follows :

I NLA and Government
IMA should pressurise the government (Director General of Health Services in each state)
for immediate formation of Appropnate Authority and Advisory Committee at all district
levels.
IMA and Medical fraternity
1. Dissemination of information about Prenatal Diagnostic Techniques Act 1994 among
doctors should be done on a war footing.

2. Doctors should be made aware of the gravity of the situation caused by selective female
foeticide and consequent demographic problems through articles in journals of IMA
and other Associations (OBST/GYN, Indian Association of Pediatrics, Ultrasonology).

3. INI A should organise similar w orkshops at the regional level, and they in turn at the
district level, to involve all sections of society in generating sensitivity and awareness
amongst doctors and the community
4. IMA should immediately set up a Steering Committee at its Headquarters, as well as at
the state and district levels, involving committed doctors/NGOs/ social activists/media
persons / educationists (from schools and colleges) and legal experts.

5. IMA should form a (render Task Force at National, state and district levels and
identify the persons and institutions interested in gender issues.
6. There is urgent need for formation of forums against sex determination and female
foeticide at all district levels, consisting of people from all walks of life, who will work
as a pressure group on doctors and society and channelise the energy' of all enlightened
people to figlit for the cause of the girl child. This group will do the spade work at
community level, help IMA to launch a frontal attack on errant doctors as well as
undertake continuous surveillance of doctors and quacks.

7. IMA and the Medical Council of India should take immediate steps against errant
doctors and quacks masquerading as gynaecologists and ultrasonologists and indulging
in the malpractice of selective female foeticide Doctors found violating the law should
face automatic suspension or cancellation of registration.

1

8. IMA should immediately constitute a nucleus of legal and medical experts to examine
the existing laws and draft a legal document to be put to government for amendment of
existing laws.

9. Registration and licencing of ultrasound centres and genetic clinics must be made
compulsory as only l°o clinics and centres in the country are registered.
10. IMA should pressurise professional medical associations (Federation of OBST/GYN
Societies of India. Indian Association of Pediatrics , Ultrasonologists .Association of
India) to take a stand on gender issues, female foeticide and female infanticide. Joint
support would strengthen the cause. Iliese associations should widely publicise the
Prenatal Diagnostic Techniques Act 1994 in their journals and ensure that their
members follow it strictly.

11. IMA should appeal for greater commitment on the part of all lady doctors, women's
organisations, women joumalists/actrvists in order to sensitise society on gender issues.
Foeticide and second trimester terminations
1. IMA and FOGSI must remind members that under the Indian Penal Code female
foeticide is a punishable offence (10 years imprisonment)
2 Second trimester abortions should be only performed in case of
a) Proven congenital malformation or genetic defect in the foetus.
b) Pregnancy following rape.
c) Grave risk to the life of mother.

3. Gynaecologists and registered doctors must record the sex of the foetus for all second
trimester abortions
4. Specific cause of termination must be mentioned and not dubbed under “good faith”.
“trauma to the mother” or simply “contraceptive failure.”

Public awareness
1 There is urgent need to make society aware of the PNDT Act. NGOs, “anganwadi”
workers, senior citizens and the media should undertake the responsibility of spreading
awareness in the local language.
2. Involve the local community in spreading awareness through street plays, etc. on
various gender and related issues.

3.

AU ministers, MPs and MI As should be made aware of the problem and they should
work out strategies to resolve the problem of female foeticide/inf anticide in their
constituencies.

4.

Since the media (print/electronic AIR) plays an important role in creating public
awareness, it should be involved in making the fight against female foeticide/infanticide
a people’s movement.

2

4

5. IMA should approach a few multinationals to buy time to disseminate key messages on
television by sports and film celebrities and request sensitive media persons /film
makers to make small films or documentaries on the plight of girl child, female
foeticide and female infanticide.

Achievements of the National Workshop on “Gender Bias :
Female Foeticide/Infanticide”
Dr. Sharda Jain, Organising Secretary7, summarised the achievements of the workshop:

1. Thanks to the overwhelming interest and response of all representatives of government
departments, NCW, international agencies, educationists, NGOs , social activists and
above all media persons, we now have 200 dedicated people from all walks of life who
all National taskforce , gender bias on female foeticide/infanticide and pledged to
workfor them. (??)
2. There was individually with missionary zeal of obvious increased awareness among
participants ofPNDT Act, laws on female foeticide andfemale infanticide and misuse
of liberal MTP Act. (??)
3. Participants felt that the process of formation of Appropriate Authority and Advisory
Committee had to taken up seriously with DGHS of each state so that the registration
of genetic clinics and ultrasound centre is done without delay, which is again a healthy
awakening.

t

4. President of Medical Council of India and Hon’ble Minister of Health and
Environment, Delhi Government, appreciated the efforts of IMA Women’s Wing and
UNICEF and assured the House that there would be strict and speedy implementation
of law and derecognition of license to practice of errant doctors on complaint of
female foeticide by IMA or Steering Committee of IMA.

5. The great moral support and cooperation of media was reflected in the excellent
coverage both before and after the National Workshop. In fact a fear complex has
already spread the medical fraternity which IMA, MCI and government should encash
on.

3

v;

Brainstorming session on Female Foeticide held on 16 September, 1999

Main Points
1. Since the MTP Act permits termination of pregnancy before 20 weeks, one cannot ban female
foeticide per se. However, it is found that as a result of various diagnostic techniques that are
available, the sex of the child gets determined resulting in abortion of female foetuses. Therefore
the PNDT Act prohibits the use of sex-determination tests itself. It also provides for an
Appropriate Authority (AA) which is responsible for registration of the genetic counselling
centres/clinics/ labs, maintenance of standards in these centres, and investigating complaints of
breach of the provisions of the Act. No Court can take cognizance of an offence under the Act,
except on complaint made by the AA or a person who has given a notice of not less than 30 days
to the AA of his intention to go to the Court with the complaint.

2. We must note the difficulties in the effective use of criminal sanctions in cases where both the
>arties are willing partners in the offence being committed. However, criminalisation itself can
serve a limited purpose of laying down the legal norms for actions which cannot be tolerated by
society.
3. The usefulness of having a body like the AA which screens the complaints needs to be
examined. The purpose of this body screening the complaints needs to be questioned. Can the
practice of female foeticide be looked at as a public wrong with space for anybody to take the
matter to the Courts directly? Can the composition of the AA be enlarged so that the present
danger of medical practitioners within the AA protecting their peers who commit the offences
maybe reduced?

4. One has to critically examine the problem in the context of technology that is advancing rapidly.
The use of technology would have to be carefully regulated. With the technological progress, the
period at which the sex of the foetus can be determined is going to be advanced. How does one
take this into account while trying to regulate the use of such technology by law?
5. How does one regulate the interaction between the doctor and the patient by law?

6. If a pregnant woman is able to get the sex of the foetus detected by escaping the regulation
under PNDT, and if the foetus is a female foetus of less than 20 weeks, the woman can legally
abort the foetus. Since there are no records of the sex-determination test, it is not possible to
assume that the foetus killed was a female foetus. Should one, therefore by law, turn the premise
and make it mandatory for the sonologists to record the sex of the foetus but not reveal the same to
the client? Will this still be subject to the same loopholes of incorrect recordings, etc. How does
one prove that the abortion within 20 weeks of the female foetus was on account of the fact that
the foetus was a female and not on any other grounds specified in the MTP Act, like the failure of
contraception?
7. Can the ground of mental trauma be used to abort a female foetus under the MTP Act

8. Right of the female foetus to be bom has parallels with the Right of tlie foetus with
disabilities/deformities to be bom. This confronts us with a question of right of a female foetus or
right of a foetus with defomuties to be bom versus right to the woman to choose whether she
wants to continue with her pregnancy. What if the woman wants to terminate the pregnancy
because the foetus is a female?

9. Any attempt at curbing the practice of female foeticide will have to also look at the MTP Act
which would raise larger issues and may have to keep in mind the long and also a strong struggle
from the women’s lobby which led to the MTP Act.
10. Can law on female foeticide be an answer to the problem of female foeticide or should one
address the root causes of the problem through social interventions to empower the women,
granting equal property rights, through incentive prorgrammes that existed during the British
period, etc.

11. The larger questions of medical ethics and monitoring the same needs to be seriously addressed
as the problem of female foeticide can be significantly controlled with the active support of the
medical profession.

I

To

C0KSULTAT10K OK FEMALE FETICIDE -PROS^ftHME
2nd December:
9.00 am. - 9.30 am. Registration
Dr. V. Beniamin
Session-1
Moderator
Welcome Address
9.30 am. - 9.35 am.
9.35 8_ni -10.00 a.m.

Inaugural Address

10.00 a.m. -10.20 am

Need and Perspectives for
Consultation
Campaign Against Pre-natal SexSelection: Perspectives, Strategies
and Experiences
P.eflection from participants

10.20 am -10.40 am

10.40 am. -11.15 am
Sesgon-2
Moderator
11.15 am -11.35 am.
11.35 am. -12 noou
12 noon -12.20 p.m
12.20 p.m. - 1.00 p.m.
1.00 pan. - 2.00 p.m.

Moderator
Session-3
2.00 p.m. - 2.20 p.m.

2.00 p.m. - 2.40 p.m

Ms Rgnjam KMnrtlsy
Female Feticide from Feminist
Perspectives
Comments
Diiemma in providing Abortion
Services to Poor
Comments

: Ms Mounam,
Vice-President, SIRD
: Dr V.Benjamin
Community Health Cell, Bangalore
: Dr Sabu M. George

: Mr RP.Ravindra
FASDP, Mumbai

: Dr Gabriele Dietrich
CSA, Madnnd.
: Ms Ranjam
: Ms Burnad Fatima
SEED, Arakkonam
: Ms Uma M^eswsi

Lunch
Dr Sabu M»George
Critical Assessment of fee
Implementation of the National A_ct
Board of the 1996 Act
Comments

Session-4
Mod^Mor
2.40 p.m. - 3.00 p.m.

Dr. Sr Henalng
Ethical Use of Ultrasound in
Pregnancy

3.00 p.m - 3.20 p.m.

Comments

Session-5
Moderator
3.20 p.m. - 3.40 p.m.

Mr Ossie Fernandez
Legal and Judicial Framework Female Feticide

: Mr R.P.Raviudra

: Dr S.Siresh
Mediscan Prenatal Diagnosis
Fetal Therapy Centre, Chennai.

: Dr (Ms) Archana, National Law
School of India University
Bangalore

3.40 p.m -4.00 p.m.

4.00 p.m - 4.30 p.m.

Female Feticide - Legal perspective : Ms C. Jesuretfainam
Advocate, Nagapattinam
Comments

%

Session-6
Moderator
4.30 p.m .-4.50 p.m

Dr, Saba M George
Measuring Feticide in Rural Areas

4.50 p.ni -5.00 p.m.

Comments

: Dr Kuryan George
CMC, Vellore

3rd December:
Session-1
Moderator
9.30 am - 9.50 am

9.50 a.m-10.00 a.m
10.00 a.m.-10.15 a.m.

10.15 a.m.-10.30 a.m.

Ms Gandimathi
Special Address - A reflection on
Female Feticide in Tamil Nadu
Child Sex-ratio in Usilampatti Micro study
Role ofTNVHAI in preventing
Sex selective abortion
Abortion services to poor women Hyderabad Experience

Session-2
Concluding Session Mr MJfeeva
10.30 am -11.30 am
Towards building a Campaign

11.30 am. -11.50 am.
11.50 am. -12.45 p.m
12.45 p.m -12.55 p.m
12.55 p.m - 2.00 p.m

Tea Break
Strategic planning
Draft Consensus Statement
Finalisation of Consensus Statement

: Dr Asha Krishna Kumar
Front Line, Chennai
: Ms C.Mounam, SIRD
: Ms J.P.Saulina Arnold
TNVHA, Chennai
: UmaMaheswari
NIRNAYA, Secunderabad

: Ms Sudha, Dr. Daisy Dhannaraj
Ms Mina Swaminathan, CRY,
Action Aid, National Foundation
for India

Dr Sabu M.Geofge
Dr Sabu M. George

I
I

I

I

Female Infanticide in Rural South India

I

Sabu George
Kajaratnarn Abel

I

I
i

i

B I) Miller
Infanticide has been practised in all continents, but little dependable primary data exists on this subject. Presented
here are findings on female infanticide for a rural south Indian population. These data were collected as part
of a major four-year field study on child growth and survival in a 13,000 population and have been confirmed
directly with the families concerned. Female infanticide is practised in only 6 of the 12 study villages affecting
about 10 per cent of new-born girls. Reported here are the demographic consequences and social factors associated
with this are considered. Seventy-two per cent of all female deaths were due to femicide and misclassification
of these deaths would grossly distort the significant child survival achieved by this population.
AMONG humans, infanticide is a
longstanding and widespread practice.1 The
study of infanticide among humans its
motivations, methods, and determinants
has a long history extending from commen­
taries of early travellers to contemporary
fieldwork-based studies. Inng-term scholar­
ly interest in the subject of infanticide,
however, and decades of intensive anthro­
pological field work on the related topics of
household formation, birth practices, and
child care yield surprisingl> little dcjx.ndable
information on infanticide, c.speciall> direct
infanticide. It is difficult to obtain firsthand,
carefully confirmed data on it fanticide cases
and the social variables related to infanticide,
in sufficient quantity to allow theory testing.
Absence of information on direct or in­
direct infanticide in a given study does not
necessarily mean that such practices are in
fact non-existent. The researchers simply
may have overlooked them, intentionally or
unintentionally. Several reasons explain
scholarly inattention to.infanticide Most im­
portant, there is the problem of gathering
enough data on direct or indirect infanticide
through a brief field trip Even in a large
study population (of over a thousand, lor
instance), the number of infanticides that
might occur is small, lor example, Sargent,
who has written an insightful study of witch­
craft and infanticide in a west African
population, learned of five cases of infan­
ticide during her field trip of 1976-77.2 In
addition to the problem of small numbers
of cases, the subject of infanticide bears a
certain amount of stigma for both the
population concerned and the anthro­
pologist who studies it.
Therefore, most anthropological studies
of deliberate and direct infanticide, in par­
ticular, rely on inferential evidence, largely
secondhand reports from informants who
inform the anthropologist of infanticides
they have heard about.’ In such local
studies of direct infanticide, numbers of
reported cases are still quite small, thus
limiting theory testing and analysis. For in­
stance, in their study of the Tarahumaia of
Mexico, Mull and Mull interviewed 20
women about their knowledge of infan­
ticide.4 They found that 95 per cent of the
women knew of .it least one case of inlan
(itide when the mothci had no husband >>1
had ‘too man) vhildicn, 55 per cent knew

I conomic and I'oliikal Weckh

of at least one case of infanticide of a
‘damaged’ child, and 10 per cent knew of
at least one case in which a sickly infant had
been killed. All the women questioned knew
of at least one such circumstance. Due to
limitations of their data, Mull and Mull can
provide little insight beyond this basic infor­
mation bn people’s knowledge of various in­
stances of infanticide, the methods used, and
iome anecdotes. Bugos and McCarthy’s
study of infanticide among the Ayoreo, a
tribal population of south western Bolivia,
involves a more quantitative approach.5
Their fieldwork, conducted from January
1980 to March 1981, provides information
on many more cases of infanticide than they
discuss since they limit their study to “well
documented cases in which the mother was
a party to the decision to kill the child.
. and to only those cases in which the sex
of the infanticide victim is known’’6 They
are concerned mainly with the reasons for
infanticide, and their analysis reveals two
general patterns: infanticides due to the con­
dition of the mother or infant, and infan­
ticides due to uncertain social or physical
factors (such as being resettled on a reser­
vation). Analysis of the marital histories of
the mothers involved reveals the overarching
importance of marital instability.
Larger state-level populations can be
studied through archival data, such as parish
records or early censuses.7 But this strategy
is constrained by the necessity of having to
infer infanticide from the data and the lack
of firsthand observational insights on related
aspects of the society under consideration.8
A contemporary analysis of official
statistics on infanticide cases in Canada,
alternatively, provides direct and confirm­
ed evidence in 148 cases for 196I-1979.9 But
like the historical/census-based studies, this
one is limited in its ability IO provide
understanding of social context and motiva­
tions. The authors are removed from the
people who committed the infanticide; they
cannot interview them and must instead
infer motivations on the basis of the
sccial/cultural data available, such as age
and sex of the victim, age and sex of the
person who killed the infant and relation­
ship to the infant.
in an extensive informant-based study of
ini.niiKidc, Nulini examines 250 cases of in­
fanticide in an area of rural Mexico which

Ma\ AO. 1992

are definite and confirmed on the basis of
detailed interviews.10 Many of the cases in
the study occurred while Nutini was in the
field, but others are included on the basis
of recall and are thus not as reliable in their
details as the others. His detailed research
on infanticide is possible because of his long­
term residence in the area (every summer
over the past 30 years), widespread social
networks, and rapport wjth the people of
several villages. The data reveal a complex
pattern of witchcraft beliefs as ideological
justification for the infant deaths, and social
patterning of the victims whereby high parity
children are killed and girls more frequently
than boys in recent times.

Study Area and Population
The larger study, of which the infanticide
data constitute one part, was conducted in
a rural area in the South Indian state of
Tamil Nadu. The research was carried out
in 12 villages of K V Kuppam block, North
Arcot Ambedkar district, Thmil Nadu state,
South India, for four years beginning in
September 1986.11
'
The 12 study villages arc noncontiguous,
scattered in the peripheral areas of K V
Kuppam block. Most villagers are Hindus,
and a small proportion are Christian con­
verts. While villages in the study area differ
slightly from each other in their caste com­
position, the average distribution is 56 per
cent gounders, 31 per cent harijans, 11 per
cent other backward castes, and 2 per cent
forward castes.12 Sixty per cent of the
mothers in the study are illiterate.
Socio-culturally, the study'area is Dravi­
dian, a term which implies, in addition to
language, distinct features of marriage,
intrahousehold dynamics, female status, and
other practices, in comparison to non­
Dravidian north India.1’ Most notably,
characterisations of Dravidian sociocultural
dynamics emphasise consanguineous mar­
riages, sometimes between uncle and niece,
first cousins or more extended kin relations
within the same village or micro-region,14
relatively equal treatment of sons and
daughters in terms of food and medical care,
and relatively high status of adult women
within the household vi.s-a-vis males in the
same household. Literacy rates of women are
higher in the south than the north, and cur-

1153

I

I

fently all new teachers in government
primary schools in Thmil Nadu must be
women. Fertility rates lend to be lower in the
south than the north.’5 The Thmil Nadu
state government has instituted special
monetary incentives for weddings of girls
above the age of 18 years who have com­
pleted the Sth standard. Sex ratios (both for
the juvenile and total populations) in recent
decades have been near equality at the
district level.16
None of this, however, should be taken to
imply that gender equality prevails in South
India. Instead, one should realise that gender
inequality exists, but is less extreme than in
India’s north-west. Furthermore, it should
be remembered that this typification is
drawn in very general comparison to the
more patriarchal north-west and should not
be assumed to apply to all contexts in the
south where considerable variation from the
general pattern can be found within a region,
village, or even family.
The data, on female infanticide wejre
gathered as a part of a prospective study earn
ried out during April I, 1987 to September
30, 1989. All pregnancies in the 13,000
population during this period were follow­
ed. The study includes a total of 773 birth
o
mes involving 772 married women and
Oi. unmarried woman. There were 766
singletons and seven sets of twins. Total live
births were 759 of which 378 were male and
381 female. The observed sex ratio at birth
is not significantly different (at p = 0.05)
from the standard sex ratio at birth of 105
males to 100 females, observed in large
populations worldwide Of the 21 stillbirths,
eight were male and 13 female.
Each village had an assigned village level
worker whose primary function was to pro­
vide education about child care to village
mothers. The worker in all cases was a local
resident of the village and had been trained
at RUHSA (Rural Unit for Health and
Social Affairs, headquartered in Kavanur
village). The village worker’s normal duties
included keeping track of reproductive events
among the entire village population, a task
which was accomplished through visiting
each home every 10 to 12 days. Every house
in which an infant is born is visited within
two days of the birth. Such regular home
v' ng generates high quality household
c.
/graphic data since no pregnancy and
its birth outcome can be overlooked by the
health workcis.
The fact that an infanticide has been com­
mitted is widely discussed among the village
women. To the outsider, however, the cause
of death is misreported. The village worker,
thought is from the same village and is aware
of the possibility of infanticide. This is con­
firmed with the mother and immediate
relatives. Alter about five months following
the establishment of excellent rapport with
the study families, the field team had
knowledge of the intent of infanticide even
before the birth occurred in many cases. The
father or other family members would tell
the village worker that if the current
pregnancy resulted in the birth of a female.
it would be killed.

1154

The infanticide data on which this paper
is based, therefore, are unusually depen­
dable. The reported number of cases is a
conservative estimate. At least three other
female infant deaths during the period are
likely to have been infanticides, and uncon­
firmed female infanticide may account for
the disproportionate number of females (13
ouj of 21) reported as stillbirths (infanticide
at birth may be misreported as ‘sevappu—
blue baby syndrome—or as a stillbirth).
These deaths are probable, but not certain
infanticides, and thus they are not included
in this study as infanticides. Also not includ­
ed are female infanticides that occurred
before the
reference
period
or
subsequently.17
Other information gathered concerns the
village in which the infanticide occurred;
caste of the household in which the infan­
ticide occurred; age, sex and birth order of
the reference infant; twinship status of the
reference infant; and marital status of the
mother. The following discussion reports on
the analysis of these variables in relation to
the cases of female infanticide.

Patterns of Infanticide
In the study population of 13,000 there
were a total of 773 birth outcomes record­
ed, involving 759 live births of which 378
were male and 381 female. Among the
cohort of live born infants, 56 died in the
period of two and a half yeais (from April 1,
1987 to September 30, 1989), and of these
there were 23 males and 33 females. Thus
the male to female mortality ratio was about
3:4, a very low ratio corrtpared to worldwide
statistics for societies where gender bias
toward infants is not significant which in­
dicate slightly higher male mortality in in­
fancy and early childhood due to the
biological higher vulnerability of boys.
Of these deaths, 19 were confirmed infan­
ticides. In other words, of the total 56 deaths
more than one-third were confirmed infan­
ticides. Of the 23 male deaths, there was no
infanticide. Among the 33 female deaths,
there were 19 infanticides. Thus more than
half the female deaths in the 12 study
villages were due to direct infanticide; in the
six villages in which all the infanticides oc­
curred, infanticides constitute 72 per cent of
female deaths (excluding the only case of the
female infanticide to the unwed mother).
Thus, the ‘natural’ death rate in this area for
female infants is substantially increased
through the practice of direct infanticide.18
Using the infant deaths of the two one-year
cohorts (obtained by following each year’s
cohort prospectively for one year) an infant
mortality rate (IMR, deaths per 1,000 live
births) of 69 was obtained for the whole
study population; if we subtract out the
deaths due to female infanticide, the IMR
drops to 46. Put another way, in the six
villages where female infanticide is practised,
female infanticides constitute 9.7 per cent of
all female births.
Only, female infanticide occurred during
the study period. However one case of male
infanticide had occurred just before the

beginning of the study period (February
1987), where the mothei lost her husband
and killed the male child soon after birth,
after which the mother remarried. In the
case of the unwed mother, she tried to abort
the pregnancy, which was unsuccessful and
committed female infanticide when it was
born. Maternal motivations for infanticide
may be said, therefore, to vary on the basis
of marital status (the mother’s motivations,
in turn, are likely to be influenced by her
natal family and their concerns for loss of
status). It is likely that, no matter what the
inlant’s gender, an unmarried or a newly
married mother who becomes widowed ma)
be impelled to commit infanticide. Unwed
motherhood as a motivation for infanticide
has been documented for historic periods in
Europe’9 and contemporary Canada.20
Another case of male infanticide occurred
after the study period, where the child had
a severe congenital anomaly. Despite utilisa­
tion of the necessary corrective surgery and
post operative care (free of cost) for over
two months, infanticide was committed the
day the child was taken home.
The prevalence of female infanticide in the
study villages corresponds with a report of
gender-specific infanticide in a nearby
population, the Kallars of Madurai
district.21 The Kallars discussed are
smallholding farmers and landless
agricultural labourers who sometimes resort
to poisoning second-born, and subsequent,
daughters. According to local hospital staff
estimates reported in the article, a very high
percentage of female infants are victims of
infanticide:
1 he statistics arc shocking. Nearly 600 female
biiths in the Kallar group arc* recorded in the
Usilarnpatli government hospital every year,
and out of these an estimated 570 babies
vanish with their mothers. . . Hospital
sources estimate that nearly 80 per cent of
these vanishing babies —more than
450- become victims of infanticide.22
This assertion implies that, within the
subgroup discussed, about 70 per cent (450
out of 570 infants) of infant girls are infanlicide cases. Such a high percentage merits
careful local investigations for confirmation,
but is not out of the realm of possibility
given historic data on similarly high rates in
north-west India during the 19th century23
and the pattern reported for a region of con­
temporary Rajasthan in which very few girls
are kept alive.24
In terms of the possible historic roots of
female infanticide (direct or indirect) in
South India, we can only speculate concer­
ning the Kallar practice,25 or what the pre­
sent study shows for K V Kuppam block,
though the PR’s field conversations reveal­
ed a pattern of at least several generations.
Adding some confirmation to the possibili­
ty that the practice is of longstanding are
some references to female infanticide in
South India in the 1800s among the Kallars,
Khonds, and Todas.26 It is possible,
therefore, that the contemporary situation
has antecedents far back in time, but at­
tempts at more detailed historical
reconstruction have yet to be made.

Economic and Political Weekly

May 30, 1992

I

One of tl
ing results
demarcated
fanticide ca
ticidc occu
which are i
the other s
Overall (all
firm the pe
its effects c
12-village s
ratio (fema
study was 9
infanticide
939.8, whi
1018.6. Sex
reflect this (
a surplus o
a surplus c
during four
stances of c
quently in
The villt
occurs tend
less educat
with no ca.r
located in
the block,
more not;
villages. O
only two I
non-infan
bus servic
The cast
the female
other villa
ly gounde
other cash
infanticid
among th
case occu
biers), a
thatis, lik
sanguinec
among th
riages are
quent are
and first
villages v
rates of
(almost 6
the non-i
cent of
reference
of marrii
infanticic
in the inf
significar
it involve
than in I
fanticid
hypergan
Anoth
villages v
is that th
the twinf
period ofborn in
other cu
female tv
infantici
female-f
study art

Econom

(February
r husband
fter birth,
ed. In the
d to abort
essful and
ten it was
nfanticide
«the basis
nivations,
ed by her
or loss of
what the
r a newly
owed maj
e. Unwed
ifanticide
periods in
'anada.20
occurred
child ha^
te utili
Kcry anu
* for over
litted the
ide in the
rport of
nearby
vfadurai
sed are
andless
es resort
sequent,
ital staff
ery high
2tims of

3 female
xl in the
ry year,
babies
ospital
:ent of
than
22

n the
t (450
nfanucrits
it ion,
^ility
■tes in
■jry23
■con■ girls

|s of
b in
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I
One of the most interesting and perplex
of direct infanticide, but the senior author
unlikely, however, that ‘development’ in itself
I ing results of this analysis is the cleaily
is aware that a female twin may be more sub­
would be sufficient in the short run, since
I demarcated village clustering ol female in
ject to neglect than a male twin, and a
it has been found that, with increased
I fanticide cases. All 19 cases of female infan­
female infant born after a set of twins is very
resources, people who disfavour daughters
ticide occurred in six of the study villages
likely to be killed.
and favour sons follow a pattern of divert­
which are in the same part of the block; in
lhe age at which death occurred is
ing even more resources. to sons than
the other six villages there were no cases.
predominantly very young. Seventeen of the
daughters. Second, a simple biomedical ap­
Overall (all ages combined) sex ratios con­
19 female infanticides occurred within seven
proach to improved infant mortality rates in
firm the pervasiveness of (his pattern and
days of birth, one on the ninth day after
the area would have only a small effect in
its effects on village demographics. In the
birth, and the remaining one on the 16th day.
changing the ‘unwanted’ status of certain
12-village study population, the overall sex
In the entire study population, there were
daughters.
A holistic approach is required
ratio (females per males) at the time of the
a total of 18 female infant deaths during the
for changing such a complex system of
study was 977.5. In the villages where female
first seven days after birth, and 17 of these
values about girls and women, and exten­
infanticide was practised, the sex ratio was
were confirmed infanticides (the single non­
sive
study of the underlying social dynamics
939.8, while in the other villages it was
infanticide death was due to prematurity of
in this micro-region (such as marriage
1018.6. Sex ratios in the under-five age group
the infant). Thus, the first week of life is ex­
payments, marriage links among villages,
reflect this different distribution as well, with
tremely risky for female infants, but not
women’s economic opportunities, etc) would
a surplus of boys in the former villages and
because of ‘natural’ causes.
be helpful in constructing needed policies to
a surplus of girls iq the latter at all times
Notably, only one female infanticide (by
reduce female infanticide.
during four years. Also, the PR observed in­
a married mother) involved a first-born
stances of deliberate female neglect more fre­
In terms of public health involvement, the
daughter. All the other victims had birth
quently in the former than the latter.
intensive home visitation system has been
orders greater than one, and each of these
The villages in which female infanticide
shown to be effective elsewhere in India,12
families had at least one surviving female
in co-ordination with carefully maintained
occurs tend to be even more remote and ha^-c
child at the time, and usually they had two.
less educated populations than the villages
household-by-household records on births,
This pattern corresponds to the well known
in reducing deaths of unwanted daughters
with no cases of female infanticide. They are
parity-specific practice of female child
located in a hilly and more isolated part of
and promoting pregnancy planning to pre­
neglect in north-west In4|a which seems to
the block, cut off from outside influences
vent future unwanted births. Also related,
protect and preserve first-born daughters but
and
on the positive side, is the recent decline
more notably than the non-infanticidal
discriminate against higher parity
villages. Out of the six infanticidal villages,
in fertility rates in the area,33 a possible in­
daughters.30 Discrimination in child treat­
only two have bus service, while in the six
dication that fewer unwanted daughters are
ment based on the child’s gender interacting
non-infanticidal villages, all but one have
being born and thus fewer becoming victims
with birth order has also been documented
bus service.
of infanticide. The option of sterilisation by
in Tokugawa Japan.31
The caste composition of the villages with
women who have obtained the desired
Although the gounders involved in female
the female infanticide cases differs from the
number and gender composition in their off­
infanticide live in remote villages, they are
spring may significantly reduce the number
other villages in that they are predominant­
ihe upper social stratum of their villages. In
ly gounder, with lower proportions of the
of unwanted female births. Other govern­
fact, gounders own a significant proportion
ment policies related to raising the status of
other caste groups. Of the JL8 cases of female
ol the land in North and South Arcot
infanticide (of married mothers), 17 were
women may also have a beneficial impact:
districts. To assert that, relatively speaking,
scholarships for women students, special
among the gounders. The remaining one
the gounders are well-off does not mean that
emphasis on women in poverty alleviation
case occurred among the arunthatis (cob­
they do not feel economic pressures when
programmes, reservations (reserved siots) in
blers), a scheduled caste.27 These arun­
it comes to raising daughters. As in north­
local community organisations for women,
thatis, like the gounders, arc a highly con­
west India, it is precisely the costs of rais­
and special care for widows. One recent in­
sanguineous group. No cases occurred
ing daughters according to upper-class rules
<
dication of Thmil women’s relatively high
among the harijans. Consanguineous mar­
that create severe constraints on household
<
status and position, even in the public do­
riages are common in this area. Most fre­
finances.
main, is their use of voting power to have
quent are marriages between uncle and niece,
prohibition reinstated.
and first and second cousins. In the six
Excess Female Mortality
This study of a south Indian population
villages where female infanticide occurs,
is a positive step forward in that it provides
rates of consanguinity are much higher
The data on 12 South Indian villages
information that can be useful to planners
(almost 65 per cent ol the families) than in
discussed here show unequivocally that
in many different fields of effort. As a re­
the non infanticide villages (about 40 per
female infanticide greatly increases the area’s
cent note drawn from the newsletter Sq/e >
cent ot the families). Specifically, in 1 female infant mortality level. Indeed, if one
Motherhood comments, ‘‘Such measures
reference to uncle niece marriages, 6 per cent
were seeking to explain high rates of infant
can only be successful if better data—
of marriages are of this form in the non­
mortality in this region, ignoring the role of
separate information about girls’ and boys’
infanticide villages, while 11.2 per cent are
direct female infanticide would entail
mortality rates, for instance—are available
ip the infanticide villages. This correlation’s
overlooking the cause for the majority of
to planners of health and education. Girls
significance has yet to be explained, since
female infant deaths.
are the future of all nations, so it is high time
it involves a very different kinship dynamic
The results of this study present a
the scales were balanced.”34
than in India’s north-west where female in­
challenge to concepts about the benefits of
fanticide is clearly associated with
rural socio-economic development and
Notes
hypergamy and extensive exogamy.
biomcdically-oriented health care program­
[The study on growth of pre-school children of
mes. First, this research suggests that the
Another distinguishing feature of the
which this was an incidental part was funded
villages in which female infanticides occur­
villages where female infanticide occurred
by
UNICEF and Thrasher. We would like to
is that they also are the villages in which all
red are less ‘developed’ in terms of urban
thank D V Mavalankar, P Visaria and L Visaria
the twins were born; over the entire study
linkages, services, and education than the
for their suggestions.]
period of two and a half years no twins were
non-infanticide villages. Although one can­
1 See reviews in Mildred Dickemann,
born in the other villages.28 As in many
not assume simply that bringing ‘develop­
‘Demographic Consequences of Infanticide
ment’ to the more remote and less
other cultural contexts, the chances of a
in Man’, Annual Review of Ecology and
‘developed’ villages would necessarily bring
female twin dying through direct or indirect
Systematics, Vol 6, 1975, pp 107-37; Barbara
about an immediate reduction in female in­
infanticide, in either a male-female or
D Miller, The Endangered Sex: Neg/ect of
fanticide, this is a possibility that should be
female-female set, are very high.29 In this
Female Children in Rural North India
(Ithaca, NY, Cornell University Press, 1981,
held open for further investigation. It is
study area none of the (wins died as a result

Economic and Political Weekly

May 30, 1992

1155

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Ch 2); Susan C M Scrimshaw, ‘Infanticide
in Human Populations: Societal and Indi­
vidual Concerns’ in Glenn Hausfater and
Sarah Rlaffcr Hrdy (eds). Infanticide: Com­
parative and Evolutionary Approaches
(Aldine Publishing Company, Hawthorne,
NY, 1984, pp 439-62); and Sheila
Johansson, ‘Delayed Infanticide' in Glenn
Hausfater and Sarah Blaffer Hrdy (eds),'
Infanticide: Comparative and Evolutionary
Approaches, (Aldine Publishing Company,
Hawthorne, NY, 1984, pp 463-85).
2 Carolyn Sargent, ‘Born to Die: Witchcraft
and Infanticide in Bariba Culture’,
Ethnology, Vol 27, 1988, pp 79-95.
3 The literature on indirect infanticide (which
results mainly from lack of food, medical
care, and other kinds of life-supporting at­
tention to an infant) is relatively abundant
and based more on firsthand evidence of
intrahousehold discrimination. For exam­
ple, on north India: B D Miller (cited in note
1); on Bangladesh: Stan D’Souza and
Lincoln C Chen, ‘Sex Differentials in
Mortality in Bangladesh’, Population and
Development Review, Vol 6, 1980,
pp 257-70; Lincoln C Chen, Emdadul Huq,
and Stan D’Souza, ‘Sex Bias in the Family
Allocation of Food and Health Care in
Rural Bangladesh’, Population and
Development Reivew, Vol 7, 1981 pp 55-70;
on pre-20th century Europe: Johansson
(cited in note 1); and on 19th century
America: E A Hammel, Sheila R Johans­
son, and Caren A Ginsburg, ‘The Value of
Children during Industrialisation: Sex
Ratios in Childhood in Nineteenth-Century
, America’, Journal of Family History, Vol 8,
1983, pp 346-66.

8 Anthropologist G W Skinner is an excep­
tion since he has undertaken fieldwork in
contemporary Japan to complement his
analyses of archival data on the Tokugawa
period.
9 Martin Daly and Margo Wilson, ‘A
Sociobiological /Analysis of Human Infan­
ticide’ in Glenn Hausfater and Sarah Blaffer
Hrdy (eds), Infanticide: Comparative and
. Evolutionary Perspectives.
10 Hugo G Nutini, ‘Tracjitional and Contem­
porary Configuration of Infanticide in the
Tlaxcala-Pueblan Valley, Mexico’ in Hector
Correa (cd), A Comparative View of the
Ethical, Social and Technological Aspects
of Unwanted Pregnancies and Their Out­
comes, Praeger, forthcoming.
11 Sabu George gathered the data on female
infanticide as an incidental part of his study
of infant and child growth and survival pat­
terns. During his first six months in the
field, he noticed several cases of female in­
fanticide and therefore felt the need to study
this subject. The data reported here,
therefore, are dated from April 1987 rather
than from September 1986 when he first ar­
rived. It should be remembered that, while
his initial purpose was not to study infan­
ticide, it was necessary to do so because
these deaths were not amenable to preven­
tion by the u^al health and nutrition
education strategies and thus present a
special challfn^e to child survival
programmes, j
12 For information on the meaning of the
terms Other Backward Castes and Forward
Castes, see Marc Galanter, Competing
Equalities Law and the Backward Classes
in India, University of California Press,
Berkeley, 1984.
4 Dorothy S Mull and J Dennis Mull, ‘Infan­
13 See the classic work by Irawati Karve,
ticide among the Tarahumara of the
Kinship Organisation in India, (Asia
Mexican Sierra Madre’ in Nancy ScheperPublishing House, New York, 1968) and
Hughes (ed), Child Survival: Anthro­
more recent studies: David E Sopher, ‘The
pological Perspectives on the Treatment and
Geographic Patterning of Culture in India’
Maltreatment of Children (Boston,
in David E Sopher (ed), An Exploration of
D Rridel, 1987, pp 113-32).
India: Geographical Perspectives on Society
5 Paul E Bugos, Jr, and Lorraine M
and Culture (Cornell University Press,
McCarthy, ’Ayoreo Infanticide: A Case
Ithaca, NY, 1980, pp 289-326); Miller (cited
Study’ in Glenn Hausfater and Sarah
in note 1); Tim Dyson and Mick Moore, ‘On
Blaffer Hrdy (eds), Infanticide: Com­
Kinship Structure, Female Autonomy, and
parative and Evolutionary Approaches.
Demographic Behaviour in India’, Popula­
6 Ibid, p 519.
tion and Development Review, Vol 9, 1983,
7 See, for example, G William Skinner, ‘In­
pp 35-60.
fanticide as Family Planning in Tokugawa
14 See, for example, P S S Rao, ‘Inbreeding in
Japan’, paper prepared for the StanfordVarious Religious and Social Groups in
Berkeley Colloquium in Historical Demo­
South India’, Human Genetics and Adap­
graphy, San Fransci^co, 1984, and ‘Conjugal
tation, Vol I, 1982, pp 15-31.
Power in Tokugawa Families: A Matter of
15 Dyson and Moore (cited in note 14).
Life and Death’ in Barbara D Miller (ed),
16 Barbara D Miller, ‘Changing Patterns of
Sex and Gender Hierarchies, New York, •
Juvenile Sex Ratios in Rural India,
Cambridge University Press, forthcoming;
1961-1971’, Economic and Political Weekly,
R Sauer, ‘Infanticide and Abortion in
June 3, 1989, pp 1229-36.
Nineteenth-Century Britain’, Population
17 Some mothers whose children were victims
Studies, Vol 32, 1978, pp 81-93; R Trexler,
, of female infanticide during the reference
‘Infanticide in Florence: New Sources and
period were known to have had their next
First Results’,. History of Childhood
female child, born after September 30, 1989,
Quarterly, Vol I, 1973, pp 98-116; Josiah
also diejrom infanticide.
Cox Russell, The Control of Lxite Ancient
18 The reader should recall that, in addition
and Medieval Population, The American
to (he cases of confirmed direct infanticide,
Philosophical Society, Philadelphia, 1985;
other female infant deaths may have been
Regina Schulte, ‘Infanticide in Rural
direct infanticides (not confirmed) or in­
Bavaria in the Nineteenth Century in Flans
direct infanticides brought about through
Medick and David Warren Sabcan (eds),
nutritional or medical neglect.
Interest and Emotion: Essays on the Study
19 Maria VS' Piers, Infanticide (W W Norton
of Family ahd Kinship, Cambridge Univer­
and Company, New York, 1978).
sity Press, New York, 1988, pp 77-102; and
20 Daly and Wilson (cited in note 9).
Linda Gail Arrigo, ‘Female Infanticide and
21 India Today, ‘Born to Die’, June 15, 1986,
Social Stratification in Republican China:
pp 10 17.
New Perspectives from the Buck Survey of
22 Ibid, p 13.
Farm Families’, paper presented at the
23 Kami Pakrasi, ‘Effect of Infanticide on Sex
Western Conference on the Association for
Ratio in an Indian Population’, Tcitschrift
Asian Studies, California State University,
fur Morphologic and A nthropologie.
Long Beach, 1985.
Vol 62, 1970, pp 214-30; K B Pakrasi and

1156

B Sasmal, ‘Infanticide and Variation of SexRatio in a Caste I’opulation of India’, Acta
Medico Auxologica [ItalyVol *3, 1971,
pp 217 28; Mildred Dickemann, ‘Female In­
fanticide, Reproductive Strategies, and
Social Stratification’ in N A Chagnon and
W Irons (eds). Evolutionary Biology and
Human Social Behaviour: An Anthro­
pological Perspective, Duxbury Press,
North Scituale, Massachusetts, 1979,
pp 321-367; Miller (cited in note I, ch 3),
and Alice Clark, ‘Limitations on Female
Life Chances in Rural Central Gujarat’, The
Indian Economic and Social History
Review, Vol 20, 1983, pp 1-25.
24 India Today, ‘Rajasthan: A -Murderous
Tradition’, Vol 13, 1988, pp 22-24.
25 See India Today (cited in note 22).
26 Edgar Thurston, Ethnographic Notes in
Southern India, Delhi, Cosmo Publications,
1975 [ 1907J.
27 1 he mother involved in this case is known
to have done a1 ty with her subsequent
female infant born after September 30,
1989.
28 The villages wheie the twins were born are
. known throughout the area for having a
high rate of twinship. For related research,
see A 11 Bittles, A Radha Rama Devi, and
N Appaji Rao, ‘Consanguinity, "Bvinning
and Secondary Sex Ratio in the Population
of Karnataka, South India’, Annals of
Human Biology, Vol 15, 1988, pp 455-60.
29 See Gary Granzberg, ‘ lUin Infanticide: A
Cross-Cultural Test of a Materialist
Hypothesis’, Ethos, Vol 4, 1973, pp 405-512;
and Susan McGeorge, ‘Twinning in
Tlaxcala, Mexico’, unpublished PhD disser­
tation, Department of Anthropology,
University of Pittsburgh, 1991.
30 Miller (cited in note 1, pp 104-05); betty
Cowan and Jasbir Dhanoa, 'T he Prevention
of TbddJer Malnutrition by Home-Based
Nutrition Eduction’ in D S McLaren (ed),
Nutrition in the Community: A Critical
L,ook at Nutrition Policy, Planning, and
Pregrammes (John Wiley and Sons, New
York, 1933, pp 339 56); and Monica Das
Gupta, ‘Selective Discrimination against
Female Children in India’, Population and
Development Review, Vol 13, 1987,
pp 77-100.
31 Skinner (cited in note 7).
32 For a discussion of Utdhiana CMC’s ap­
proach see. Barban, D Miller, ‘Female In­
fanticide and Female Child Neglect in Rural
North India’ in Nancy Scheper-Hughes (cd),
Child Survival Anthropological Pers­
pectives on the Theatment and Maltreatment
of Children, D Rcidel, Boston, 1987,
pp 95-112.
33 Shirten J Jejeebhoy, ‘Women’s Status and
Fertility; Successive Cross-Sectional
Evidence from Thmil Nadu, India’, Studies
in Family Planning, Vol 22, 1991, pp 217-30.
34 The Lancet, ‘Girls Matter, Too’, 1991, 2,
p 813.

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Economic and Political Weekly

May 30, 1992

i

To oi-K

0

Female Infanticide in Tamil Nadu
Some Evidence
Sheela Rani Chunkath
V B Athreya

This paper reports and discusses evidence from a field survey on the existence of the practice offemale infanticide
in Tamil Nadu. Primary health centre records analysed provide strong corroborative evidence that the phenomenon
is not, as earlier thought, confined to a few blocks ofMadurai and Salem districts but is seen in an almost contiguous

bell from Madurai to North Arcot Ambedkar districts of Tamil Nadu.
7 districts (out of 27) in Rajasthan, 10 out
sex ratio for the general population ofTamil
FEM ALE infanticide - the killing of female
of 63 in Uttar Pradesh, 4 out of 19 in Gujarat,
Nadu as a whole was much higher at 974
infants because they are female- has occurred
4 out of 45 in Madhya Pradesh and one
as against the national average of 929, it was
not only in several cultures across history,
(Salem district) out of 21 in Tamil Nadu.
only 937 in Salem district and 942 in
but is known to occur in contemporary
Table I presents data on juvenile sex ratios
Dharmapuri. For the 0-6 population, Tamil
societies as well [George el al 1992). Female
for Tamil Nadu and its districts from 1941
infanticide in India has been documented • Nadu’s figure at 948 was slightly above
to 1991 across censuses. Two things are
India’s at 945, but three districts - Salem,
for the period of British colonial rule by
immediately evident. First, there is a general
Dharmapuri and Madurai - reported much
veral scholars [Panigrahi 1972; Viswa Nath
tendency for juvenile sex ratios to decline.
lower values of 849, 905 and 918,
1973; Clark 1983). In the period since
Second, in the case of three districts, the
respectively. Salem district has, in fact, the
independence, the gruesome practice has
decline is exceptionally sharp: Dharmapuri,
dubious distinction of having-the lowest
been reported as occurring in many parts of
Salem and Madurai. Il may be noted that in
juvenile sex ratio of849 among all thedistricls
the country including Tamil Nadu, where the
Periyarand Dindigul (part of Madurai district
inlhecountry. According to the 1991 Census,
phenomenon is of recent origin, and was not
up to 1981), the juvenile sex ratios for 1991
there were 54 districts in the country (besides
known to exist before independence, except
arc well below the state average, though
the union territory of Chandigarh) which had
among the Thodas of Nilgiris.
higher than those for Salem, Dharmapuri and
0-6 sex ratios below 900. These districts
In respect of several standard indicators
Madurai. The general decline in juvenile sex
were located in just seven slates: all the
of health and education, Tamil Nadu is a
ratios may be related to the greater access
districts of Haryana (16) and Punjab (12),
comparatively better performer among the
various major slates. Thus, it ranked second
only to Kerala in terms of the literacy rate
Table I: Sex Ratios 1941-1991, Juvenile Population: All India, Tamil Nadu State and
Districts of Tamil Nadu
according to the 1991 Census. Ils infant
mortality rate for 1995 as per SRS data stood
1941
1951
1961
1971
1981
1991
Territory
at 56 per 1,000 live births, and only three
(0-4 Years) (0-4 Years) (0-4 Years) (0-4 Years) (0-4 Years) (0-6 Years)
stales had a lower IMR.' The state has a good
905
993
955
Dharmapuri
network of primary schools and
988
981
970
918
Madurai
1011
978
comparatively better rales of enrolment and
849
Salem
1010
1016
990
966
900
retention. Its birth and death rates do not
Tiruvannamalai
compare badly with those of many major
964
Sambuvarayar
states. Yet the practice of female infanticide
934
Dindigul
has been reported to exist in the state
962
998
988
999
995
North Arcol Ambedkar 1013
1017
981
970
1007
1015
973
u its occunence officially admitted? The
South Arcot
976
999
Pudukkotiai
first major reporting of Fl in Tamil Nadu
964
929
Pcriyar
appeared in the popular press (S H
987
978
966
969
1006
979
Coimbatore
Venkatramani)./nJiaToJay,June 15.1986).
964
Chidambaranar
This report dealt with incidence of FI in
970
978
997
Kanyakumari
966
Madurai district, and focused upon a
968
987
998
985
Nilgiris
921
particular community in rural Madurai.
984
965
1017
997
987
Thanjavur
1008
994
969
955
Several years later, in 1992, female infanticide
J 017
1005
1035
Tiruchirapalli
946
Kamarajar
was reported from Salem district, more than
970
999
986
996
999
1015
a hundred miles from the Usilampatti region
Chengai
971
Nagai
Quaid-e-Milleth
of Madurai district which had figured in the
1986 report (Viji Srinivasan,Fron//me, 1992; . Tirunclveli1042
986
995
973
955
Kattabomman
990
Asha Krishnakumar, Frontiline 1992).
Pasumpon Muthramalinga
958
Thevar
Sex Ratios
998
969
960
Ramanathapuram
1042
1015
995
976
962
987
928
969
Madras
942
Data from the Census of 1991 on sex ratio
984
94S
974
995
1010
999
Tamil Nadu
(defined as females per 1,000 males) for both
976
964
945
962
India
the general population and the juvenile

population (0-6 age group) are highly
unfavourable to women in several blocks
and districts ofTamil Nadu. While the average

Economic and Political Weekly

District names as of 1991 have been used in this table. See Table 4 for the current list, after
reconstitution and adoption of new names in 1996.
Source: Census of India, various volumes.
V

Note:

April 26, 1997

\VS-21

•

to better health care that male infants receive
than do female infants, arising from the
general patriarchal norms prevalent in society.
But the particularly sharp decline in a few
• districts appears to reflect much stronger son
preference leading to the practice of female
infanticide. This impression is strengthened
further by the data in Table 2 which show
that the three districts of Dharmapuri, Salem
and Madurai account for 41 out of 46 blocks
Table 2: Blocks of Tamil Nadu with Low
Juvenile Sex Ratios in 1991

District

i
5

I?

r

g

r
I

Total Number
of Blocks

Dharmapuri
Madurai
Salem
Tiruvannamalai
Sambuvarayar
Dindigul
North Arcot
Ambcdkar
South Arcot
Pudukkottai
Periyar
Coimbatore
Chidambaranar
Kanyakumari
Nilgiris
Thanjavur
Nagappattinam
Quaid-c-Millcth
Tiruchirapalli
Kamarajar
Chengai
TirunelveliKaltabomman
Pasumpon
Muthuramalinga
Thevar
Ramanathapuram
Tamil Nadu

Number of
Blocks with
0-6 Sex Ratio
(Rural) < 900
in 1991

8

18
21
35

10
23

18
14

nil
2

20
35
13
20
21
12
9
15

nil
nil
nil
3
ml
ml
nil
nil
nil

20
32
11
27

nil
nil
nil
nil

4

19

11
11
385

nil

nil
nil
46

Notes: 1 District names as of 1991 have been
used in this table.
2 Madras being a completely urban
district has been excluded.
Source Census of India 1991.

Table 3: Some Sample Characteristics. DPH
Survey for 1995

Item

y

No of households surveyedPopulation surveyed
Household size
Sex ratio
Birth rate
Death rate
Infant mortality rate (male)
Infant mortality rate (female)
Infant mortality rale (total)
Neo-natal mortality rate

Value

10.37,630
44,97,086
4.3
987
21.1
7.6
52.7
57.3
54.9
38.8

Source: Directorate of Public Health. Survey,
1996.

WS-22

in Tamil Nadu with a rural sex ratio of 900
or less. The other five blocks belong to
Periyar and Dindigul districts which, as
already noted, have extremely low sex ratios.
A related point that emerges is that the sharp
decline in juvenile sex ratios is a relatively
recent phenomenon. One is led to hypothesise
that this would be true of female infanticide
as well.
The data on sex ratios thus reinforces the
reports of Fl that have appeared in the popular
press from time to lime in the last decade.
However, there has so far been no systematic
documentation of the magnitudes and the
geographical spread of the practice.
In this paper, we report both direct evidence
from a sample survey of rural households
in Tamil Nadu that cbnfirms the widespread
existenceof the practice of female infanticide,
and strong corroborative evidence from
primary health centre records. We also draw
on field level interviews and on responses
to a questionnaire on female infanticide from
nearly 3,000 respondents. An important
finding that emerges is that the phenomenon
is not confined to just one block or two in
Madurai and Salem. There is in fact an
almost contiguous belt of female infanticide
territory running from Madurai to North
Arcot Ambcdkar viaDindigul, Karur,Periyar,
Salem, and Dharmapuri.

Data Sources

(i) Survey Methodology and Procedures

Reliable data on vital rates is available
through SRS, but only for the state as a
whole. The data available from the civil
registration system is known to be far from
reliable. But any serious analysis of vital
rates for purposes of policy and for address! ng
the issues of levels of and gender differentials
in infant mortality rates, and of infanticide
would be greatly facilitated by availability
of these data at district and further levels of
disaggregation. To this end, a large-scale
survey was carried out to study infant
mortality and its variation across gender in
rural Tamil Nadu. The slate has an extensi ve
network of primary health centres (PHCs),
and below them health sub-centres (HSCs).
On an average, a PHC serves a population
of around 30,000 while a HSC caters to
about 5,000 people. Tamil Nadu had, at the
time that it was decided to conduct the survey
(Februay 1996), 24 revenue distnets (RDs)
divided into 41 health unit districts (HUDs).
The sample consisted, for each revenue
district,on an average,of 40 randomly chosen
HSCs. involving a population of around two
lakhs per district. In the state as a whole (with
Chennai, totally urban district, being
excluded), a total of960 HSCs were covered.

Table 4: Gender-Specific Infant Mortalfty Rates and Gender Differentials in 1MR, 1995

Revenue District

NUie
69.0
69.2

Dharmapuri
Madurai1
Salem3

,

67.3

Tiruvannamalai Sambuvarayar
DindiguP
Villuppuram Ramasamy
North Arcot Ambcdkar
Pcrambalur Thiruvalluvar
South Arcot Vallalar
Pudukkoltai
Periyar
Coimbatore
Chidambaranar
Kanyakumari
Karur Dhccran Chinnarnalai
Nilgiris
Thanjavur4
Tiruchirapalli
Kainarajar
Chengai MGR5
Nagappattinam Quaid-e-Millcth4
Tirunelveli.Kattabomman
Pasumpon Muthuramalinga Thevar
Ramanathapuram

46.9

Tamil Nadu

62.1
52.0
49.1
53.3
49.0

45.7
49.3
37.9
43.3
19.1

52.7
48.1
46.4
62.0

45.6
47.8
45.3
56.4
56.3
87.0
52.7

Infant Mortality Rate______
Female
Person
130.8
100.3
95.6
52.2

98.1
84.5
80.2

69.9

65.9
55.6
52.6
56.3
51.6

59.1
56.1
59.6
54.3
48.2
49.0

JMR Gender
Differential
IMR (F)- 1MR (M)

49.6

46.9
49.2

61.8
31.1

28.3
5.3
7.8
7.1
7.0
6.3
5.3
2.5
-0.3

-0.5
-0.8

37.4
42.5
17.7
50.0
45.1
42.5
58.4

37.6
42.9
18.5
51.4
46.7

41.1

43.5
45.1

-4.5

41.8

-7.5
-12.2
-14.2
-18.4

42.3
37.8.
44.2
42.1
T 68.6
57.3

44.6
60.3

50.5
49.3
78.2
54.9

-1,4

•2.7
•3.0
-3.9
■3.6

4.6

Nowbifurcated into Madurai and Vaigai Veeran Alagumuthu districts
Notes'. J ___
2 Now bifurcated into Salem and Rajaji districts.
3 Renamed now as Mannar Thirumalai district.
4 A new district called A T Pannccrselvam district has now been created, comprising some
blocks from Thanjavur and some from Nagapattinam Quaid-e-Milleth.
5 Now bifurcated into Chengai MGR and Chengai Anna district.
Source : DPH Survey. 1996.

Economic and Political Weekly

April 26, 1997

Questionnaires seeking information on live
births, still births and infant deaths in the
households during the calendar year 1995
were canvassed with 10,37,630 households.
The total population covered was 44,97,086.
The survey was carried out by functionaries
of the department of public health who cross
matched the demographic events netted by
them in the field with the records of the
village health nurses (VHNs), workers of the
Integrated Child Development Services
(ICDS), and village administrative officers
(VAOs), Discrepancies that came to light
were resolved by reverification in the field
with the concerned households. While the
methodology and data collection procedures
do have limitations, they are robust enough
for establishing the fact of incidence of female
infan ticide and for demonstrating significant
gender differences in IMR and neo-natal
mortality rates.

z::) PHC Records
The PHC/HSC network referred to earlier
employs an extensive army of field staff
Table 5: Grouping of Districts by [IMR
(Female) - IMR (Male)] Values

Range of Values of
[IMR (F) - IMR (M)]

No of Districts
(Total No = 24)

Between - 5 and 0
Between 0 and 5
Between 5 and 10
> 10

5
9
1
6
3*

Source. Tabic 4.

blockwise, and the <300 of these deaths to
distributed over most villages of the state.
total female infant deaths, districiwise. The
They monitor all pregnancies, provide
results provide strong support to the picture
antenatal care, record pregnancy outcomes
that emerges from the 1996 sample survey
and monitor infant deaths. Their coverage
may be incomplete, especially on account of referred to earlier, namely, that of widespread
practice of female infanticide in a contiguous
pregnant women moving to natal homes
stretch of the state encompassing several
outside the jurisdiction of the PHCs located
districts.
where they normally reside. However, the
data collected by the field staff and entered
Infahtt Mortality Rails
into PHC records, is still useful for
comparative purposes. The absolute values
(i) Survey
of such vital rates as birth, death and infant
The sample survey conducted in February
mortality rates may not be accurate, but they
1996 provides interesting evidence on infant
are unli kely to be biased i n different di recti ons
mortality rates (IMR), genderwise. Some
across districts?
important characteristics of the total sample
The PHC records provide information on
are presented in Table 3. As already noted,
pregnancies, deliveries, births, still births,
the survey covered 10,37,630 households
early neo-natal (0-6 days) deaths, other neo­
with a total population of 44,97,086. The
natal deaths (7-27 days), and post-natal (28population was predominantly rural. The
364 days) deaths genderwise. By aggregating
sample sex ratio was 987 as compared to 98 1
PHC data, one can obtain the corresponding
for rural Tamil Nadu as per Census 1991
figures blockwise. Thus one can compute
and 1,041 asperHFHS 1992-93. The sample
IMR genderwise for every block. The field
birth and death rates are 21.0 and 9.6
staff of the public health network also obtain
respectively as against 20.2 and 9.0 as per
information on causes of infant deaths, and
SRS (three-year moving average, 1992-94).
one of the cause categories used is ‘death
The reponed IMR at 54.9 is distinctly lower
due to social cause’. This category refers to
than the SRS Figure of 61 for rural Tamil
female/male infanticide. Our perusal of PHC
Nadu in 1995. These discrepancies in absolute
data aggregated block wise shows that, while
terms notwithstanding, the overall sample as
male infanticide does occur, it is a relatively
well as those for each district are adequate
rare phenomenon. Further, where it does
enough to permit fairly robust inter-district
occur, it is highly correlated with female
infanticide. In this paper, we confine our • comparisons, and fora prima facie assessment
of gender differentials in IMR as well as (he
discussion to female infanticide. Using data
question of presence and extent of female
from PHC records of 1995. wc ha vc computed
infanticide.
the number of female infanticide deaths

Table 6: Gender Specific Infant Mortaltty Rate and Components and Sex Ratios. 1995

Male

Female

Early Neo-Natal
Mortality Rate
(0-6 Days)
Male
Female

45.0
39.7
43.7
46.6
43.1
38.4
37.5
33.7
38.1
34.2
33.6
43.3
31.7
33.4
37.7
35.4
36.0
2S.4
31.3
43.5

100.1
70.0
85.4
42.4
52.9
38.8
35.9
34.6
45.0
33.3
33.2
38.5
39.2
27.2
38.9
35.6
37.5
25.4
27.8
36.5
34.6
32.4
29.0
14.6
44.3

26.4
19.0
25.0
28.0
23.8
20.0
16.7
13.9
14.6
18.4
18.2
17.1
14.3
15.4
20.0
17.2
18.7
14.1
17.6
17.9
21.2
20.4
16.1
6.5
18.5

Name of the District
infant Mortality Rale

Dhannapuri
Madurai
’em

!
I
!

mnad
Dindigul
Trichy
Pcrambalur - Thiruvalluvar
Villupuram
N A Ambcdkar
S A Vai lai ar
Karur
Tirunelvcli
Thiruvannamalai
P M Thcvar
Periyar
Pudukkottai
The Nilgiris
Chengai MGR
Thanjavur
Kamarajar
Chidambaranar

|

Nagai
Coimbatore
Kanyakumari
Tamil Nadu

35.8
31.4
14.7
36.9

76.0
43.4
60.4
22.0
27.0
17.8
15.9
14.6
19.7
15.8
16.1
12.3
16'5
11.5
18.3
15.2.
20.5
11.1
12.9
15.6
14.3
17.6
12.9
6.6
24.0

Late Neo-Natal
Mortality Rate
(7-27 Days)
Male
Female
7.0
8.0
7.2
6.1
7.5
6.1
6.7
7.4
8.0
5.4
3.5
6.8
6.1
6.0
6.0
6.6
6.4
4.7
4.7
5.6
6.4
5.4
5.3
2.1
6.2

11.7
12.6
12.3
8.0
11.1
6.5
7.8
8.3
9.3
7.0
4.7
5.9
8.1
5.1 7.9
7.2
6.7
4.7
6.4
5.8
6.1
5.2
5.2
2.1
7.7

Sex Ratio Sex Ratio
Posi Nco-Natal
ai Birth
Mortality Rate
(28-3M Days)
Male
Female

11.6
12.7
11.5
12.6
11.8
12.3
14.1
12 4
15.4
10.4
I 1.9
19.4
1 1.3
12.1
I 1.7
1 1.6
10.8
9.6
9.0
20.0
14.S
9.9
10.0
6.1
12.1

12.4
14.0
12.8
12.4
14.7
14.5
14.2
11.8
16.0
10.4
12.4
20.4
14.6
* 10.6
12.7
13.2
10.2
9.6
8.5
15.0
14.2
9.6
10.9
6.0
12.6

938
967
937
994
971
984
970
957

1003
964
988
1007
966
996
938
995
995
976
995
994
1035
967
964
1013
974

903
922
884
913
940
922
946
942
961
953
949
967
943
979
916
935
954
951
961
945
980
929
912
990
937

Source: PHC Records 1995.

Economic and Political Weekly

April 26, 1997

WS-23

1

I

I

!

Table 4 presents sample data on gender­
specific infant mortality rale and gender­
differential in IMR for each district. There
are five districts with IMR exceeding 65; 13
districts have IMR between 45 and 65, with
the overall sample average at the midpoint
of the interval. Six districts report what are,
by comparison, ‘low* infant mortality rates,
with that of Kanyakumari resembling the
figures for Kerala.
Among the five high IMR districts, the
figures for Ramanathapuram are reported to
be under review and are regarded as
unreliable. We leave them out of our
discussion.4 The four remaining high IMR
districts are Dharmapuri, Salem, Dindigul
and Madurai. In all these cases, the female
IMR is substantially larger than the male
IMR-. Table 5 presents the grouping ofdistricts
on die basis of various ranges of value of
the gender-differential in IMR expressed as
female IMR minus male IMR. In the majority
of districts (14 out of 24), male IMR exceeds
female IMR. Among the 10 districts where
female IMR exceeds male IMR. threedistricts
- Dharmapuri. Salem and Madurai - show
female IMRs that are exceptionally high at
130.8, 95.6 and 100.3 respectively, it is. of
course, also true that these three districts
report the highest male IMRs (leaving out
Ramanathapuram for reasons already stated)
at 69.0. 67.3 and 69.2 respectively. But the
gender-differential in IMR is very large,
being, in the same sequence. 61.8, 28.3 and
31.1 points. Clearly, something more than
general backwardness in terms of health status
is needed to explain the exceptionally high
levels of female infant mortality rates in
these three districts.
(ii) PHC Records

The PHC records provide detailed data
PHC-uise on infant deaths broken into the
followi ng components: early neo-natal (i n fant
death occurring in the first six days of the
infant's life), late neo-natal (infant death
occurring seven to 27 days after birth) and
post-natal (infant death occurring after the
first 27 days but within 365 days). Gender­
specific values for infant mortality rate and
ns components can be computed from the
data. 7 able 6 presents the relevant data for
the districts of Tamil Nadu.
Certain key points emerge from an
examination of the data in Table 6. While’
several districts such as Dharmapuri, Salem,
Madurai and North Arcot Ambedkar exhibit
a significant positive differential between
female and male IMRs. the striking feature
is that there is hardly any gender differential
in post-natal infant death rates in most of
these districts. On the other hand, monality
rates are considerably higher for female as
opposed to male infants in the entire neo­
natal phase. The difference is at its sharpest
in the early neo-natal phase where female

WS-24

in 1995 were 2.60, 2.13, 2.11 and 1.30 for
Dharmapuri. Salem. Madurai and North
Arcot Ambedkar districts respectively.
Dindigul and Periyar districts, from where

infant deaths outnumber male infant deaths
by more than a factor of two in these districts.
As can be seen from Table 7, the ratios of
early neo-natal female to male infant deaths

Table 7: Female Infant Deaths: Early Neo-natal, Late Neo-natal, Post-natal and
Female Infanticide

0-6 Ratio of 7-27 Ratio of
Days Female Days Female
to Male to Male
Deaths
Deaths

District

Dharmapuri

Female

294

277

1805

Salem

306
361

183

694
1710

348

2.1
Madurai -

Male
Female

North Arcot

Male
Female

Ambedkar
Dindgul

Male
Female

1.1
202
166

367
403

Pcriyar

368

25.3
129

187
214

0.8
Male

177

22.7

1.2

1.4
119
132

378
309

45.5

1.0

388
220

1.1

Male
Female

571

309
387

1.3

50.2

1.0

1.5

195
224

461
476

1033

369
314

2.1

57.6

1.0

1.5

230
283

801
973

1199

1.0

1.5

2.6
Male
Female

28-365 Ratio of Female Fl Deaths as
Days Female infanti- Proportion
to Male cide (Fl) of Female
Deaths Deaths Neo-natal
Deaths

69

15 6

1.0

1.2

216

110

Source: PHC Records 1995.
Table 8. Total Infant Deaths, Female Infanticide Deaths and ‘Female Infanticide Rates’,
Sample Survey for 1995
District

Dharmapuri
Madurai1
Salem2
Tiruvannamalai Sambuvarayar
Dindigul1
Villuppuram Ramasainy
North Arcot Ambedkar
Perambalur Thiruvalluvar
South Arcot Vallalar
Pudukkottai
Periyar

Total Infant Deaths
Male
Female

182
149
146
89
128
118
99
108
129
I 14
101
74
Coimbatore
84
Chidambaranar
33
Kanyakumari
96
Karur Dhecran Chinnamalai
45
Nilgins
94
Thanjavur4
136
Tiruchirapalli
I 11
Kamarajar
96
Chengai MGR5
102
Nagai Quaid-e-Millelh4
130
Tirunelveli Kattaboraman
Pasumpon Muthramalinga Thevar 86
135
Ramanathapuram
2585
Tamil Nadu

308
208
174
99
135
134

Female
Female Infanticide Rate =
Infanticide . Female Infanticide Deaths
Deaths
as Per Cent of Female
Infant Deaths

183
112
58
9
28
I

59.4
53.8
33.3
9.1
20.7
0.7

1
. I

0.9
0.7

9

9.9

111

110
135
109

88
65
80
27
91
38
76
120

0.8

91

81
77
95
63

98
2613

403

15.4 ’ *

Notes: I Now bifurcated into Madurai and Vaigai Vceran Alagumuthu districts.
2 Now bifurcated into Salem and Rajaji districts.
3 Renamed now as Mannar Thirumalai district.
4 A new district called A T Panneerselvam district has now been created, comprising some
blocks from Thanjavur and some from Nagapattinam Quaid-e-Milleth.
5 Now bifurcated into Chengai MGR and Chengai Anna districts.
Source: DPH Survey. 1996.

Economic and Political Weekly

April 26. 1997

also a sizeable number of female infanticide
deaths are reported, show a somewhat
different pattern. In these two districts, female
to male infant death ratios are al their highest
levels in the late neo-natal phase. These
differences apart, what emerges* clearly is
that districts with widespread and significant
incidence of female infanticide are also
districts where female infants face the largest
proportional survival disadvantages in the
neo-natal phase. The data also suggest that
a large proportion of female infanticide deaths
takes place in the early neo-natal phase.
Female Infanticide

Evidence on female infanticide from both
the sample survey and PHC records are
discussed below:
(i) Survey

i

i

In the course of the survey, information
on infanticide was also collected. Table 8
presents data on total infant deathsand deaths
due to female infanticide. We have calculated
and reported The rate of female infanticide’
expressed as percentage of all female infant
deaths.
The results are striking and disturbing.
Ten districts report at least one instance of
female infanticide even in our relatively small
sample. A census coverage would quite
possibly reveal a wider geographical spread
of this horrifying social practice as is in fact
suggested by data from primary health centres
that we discuss later on. Four districts comprising in all eight health unit districts
(HUDs)-show very high incidcnceof female
infanticide: Dhanriapuri. Madurai, Salem and
Dindigul. in the first two, more than half of
all female infant deaths and over two-thirds
of neo-natal deaths of female infants occur
on account of female infanticide. In Salem,
a third of female infant deaths and nearly
two-fifths of female neo-natal deaths arc due
to infanticide. In the case of Dindigul, the
proportions are over one-fifth and nearly
three-tenths respectively.
(ii) PHC Data 1995

Data from PHC records provide strong
confirmation of the survey finding that the
practice of female infanticide is very
widespread in Dharmapuri, Salem and
Madurai districts. Besides these four
‘intensive female infanticide* districts, four
other districts. North Arcot Ambedkar,
Periyar, Karur and Villupuram Ramasamy,
. report a minimum of 10 female infanticide
deaths. The data are summarised in Table 9.
The eight districts where 1 Oormore female
infanticide deaths occur form a contiguous
belt. More important, as the map of infanticide
brings out clearly, there is acontiguous cluster
of blocks where female infanticide occurs.
Fuither, one can sec an emerging pattern.
Whilelhereisa ‘hardcore’ female infanticide

Economic and Political Weekly

Table 9: Infant Deaths and Infanticide as per PHC Records, Districts of Tamil Nadu, 1995
District

Male

1183
Dharmapuri
965
Madurai
]
1400
Salem
Thiruvannamalai
594
Sambuvarayar
684
Dindigul
924
Villupuram Ramasamy
957
North Arcot Ambedkar
Pcrambalur-Thiruvalluvar 391
623 ■
South Arcot Vallalar
458
Pudukkottai
694
Periyar
647
Coimbatore
491
Chidambaranar
154
Kanyakumari
240
Karur
173
Nilgiris
531
Thanjavur
588
Tiruchirapalli
542
Kamarajar
980
Chengai
772
Nagi Quaid-e-Millcth
Tirunelveli Katlabomman 900
Pasumpon
Muthuramalinga Thevar 310
Ramanathapuram
545
Tamil Nadu
15746
(excluding Madras district)

Infant Deaths *
Female
Total

Infant Deaths due to “Social Cause"
Male
Female
Total

2375
1570
2419

3558
2535
3819

57
8
58

1199
571
1033

1256
579
1118

692
789
895
1087
374
578
430
655
545
393
152
225
172
453
549
429
834
651
775

1286
1473
1819
2044
765
1201
888
1349
1192
884
306
465
345
984
1137
971
1814
1423
1675

0
3
1
I
2
0
2
0
0
0
0
I
0
0
1
1
0
0
0

2
129
11
177
, I
I
3
69
0
0
0
13
0
0
11
5

2
132
12
178
3
1
5
69
0
0
0
14
0
0
12
6
I
0
0

247
452 ,
17741

557
997
33487

0
0
162

0
0
3226

i

o
o

;

0
0
3388

Source: PHC Records.
Table 10: Distribution of Blocks by Number of Female Infanticide Deaths as per PHC Records
District

Total
No of
Blocks

Dharmapuri
18
21
Madurai
35
Salem
Tiruvannamalai
Sambuvarayar 18
14
Dindigul
Villupuram
Ramasamy „ 22
North Arcot
20
Ambedkar
PerambalurThiruvaluvar
10
South Arcot
13
Vallalar
13
Pudukkottai
20
Periyar
21
Coimbatore
Chidambaranar 12
9
Kanyakumari
8
Karur
4
Nilgiris
Thanjavur
15
14
Tiruchirapalli
II
Kamarajar
27
Chengai
Nagai Quaid-e20
Milleth
TirunelveliKattabomman 19
Pasumpon
Muthuramalinga
Thevar
I1
Ramanathapuram I I
Tamil Nadu
386

Total ______

No of >200
Fl
Blocks

No of Blocks with Fl Deaths
100 to 50 to 10 to 5 to
1-4
199
99
49
9

Total
No of
No of Blocks Not
Rcponing
Fl
Deaths any Fl
Death

4
8
8

1
I
5

2
5
5

1199
571
1033

4

4

2

2
5

2
129

16
3

1

4

I1

17

2

2

177

11

I

1

1

9

I
1
4

1
1
1

I
3
69
0
0
0
13
0
0

12
12
16
21

14
19

2

28

4

I

I
5
9

2
1I

5

1

9

4

1

2

5

5
I
1

3
1
I

105

2

2

5

16

30

15

37

12
9
6
4

1

15
17
10
26

0

20

0

19

0
0
3226

11
11
281

I1

5
1

2
7

Note: The completely urban district of Madras has been excluded.
Source: PHC Records 1995.

April 26, 1997

WS-25

»

region, comprising the northern blocks of
Salem district, the southern blocks of
Dharmapuri district, a cluster of southern
blocks of Dindigul district and of the western
half of Madurai district, what should also
cause particular concern is the manner is
which the phenomenon is spreading from the
core area to a much wider neighbouring
periphery and beyond.
Table 10 presents the distribqtion ofblocks
by the number of female infanticide deaths.
The table brings out a clear and striking
regional pattern. The southern and eastern
coastal districts as well as the cauvery delta
districts are by and large free of female
i nfanticide. So arc the districts of Coimbatore
and Nilgiris on the western border of the
stale adjoining Kerala. Leaving out
metropolitan Chennai, this gives us a
contiguous belt of panchayat unions running
from the western half of Madurai district
through .Dindigul. Karur, Periyar, Salem,
and Dharmapuri to the western end of
North Arcot Ambedkar district. Within
this belt, the PHC data broadly confirm the
picture that emerges from (he 1996 sample

survey.
While the belt of ‘infanticide blocks’ is
contiguous, the quantum of incidence of
infanticide varies considerably along the bell.
Out of 386 blocks tn the state, 105 blocks
report occurrence of female infanticide. Of
these, roughly half (52 out of 105 blocks)
report less than ten Fl deaths. Al the other
end. just seven blocks report Fl deaths
exceeding 100 each, and together account
for 1.092 Fl deaths out of a total of 3,218
Fl deaths in the entire state. Of these seven,
one was in Salem (Idappadi) while the other
six were all in Dharmapuri. Another 16
blocks, mostly from Salem (nine blocks) and
Madurai (five blocks), each with infanticide
deaths exceeding 50 but below 100. account
for 1,123 deaths. Thus 23 blocks account for
practic ally70pcr( cntofall female infanticide
deaths in Tamil Nadu in 1995 as per PHC
.cords. Less widespread but far from
negligible incidence of female infanticide is
found in 30 blocks, with the number of Fl
deaths ranging between 10 and 49. These
blocks are again concentrated in the two core .
regions of Salem-Dharmapuri and MaduraiDindigul, which between them account for
24 blocks, but there is also a spread at this
level to some of the blocks in the districts
of North Arcot Ambedkar and Periyar. These
blocks of Periyar and North Arcot districts
are the ones adjoining the core infanticide
zones of Salem and Dharmapuri. Together,
these 30 blocks account for 481 Fl deaths
in 1995 which is a little over one-fourth of
total Fl deaths in the state in 1995. Finally,
we have 52 blocks where the incidence of
female infanticide is sporadic, but which

clearly signal the grave danger of a further
and far wider spread of this heinous social

Economic and Political Weekly

practice. Several non-core districts enter the
picture here: Chengai, Kamarajar, Karur,
South Arcot Vallalar, Villupuram Ramasamy,
Pudukkottai,
Tiruchirappalli
and
Thiruvannamalai Sambu varayar. Karur, more
or less at the midpoint of the Fl belt, is
especially vulnerable. Seven of its 13 blocks
report female infanticide.

Survey and PHC Data: Some Remarks
The data from the primary survey of 1995
and those from the PHC records for the same
year broadly corroborate each other, but
there are some puzzling differences. The
estimates of the rale of female infanticide,
defined as the percentage of female infanticide
deaths to total female infant deaths, as
obtained from the survey and from PHC
records are brought together in Table 10.

Four districts figure unambiguously in both
the survey and the PHC records as major Fl
districts: Dharmapuri, Salem. Madurai and
Dindigul. The district of Karur also emerges
from both sources as an area of significant
incidence of FI. But rather surprisingly, in
the two districts of North Arcot Ambedkar
and Periyar. the sample survey did not find
a single instance of Fl, while PHC records
show 177 and 69 Fl deaths respectively in
these two districts. In the case of Periyar.
only two blocks - Amma|>el and Bhavani
- report a significant number of Fl deaths
as per PHC records. It is thus possible that
the sample survey may have missed oul Fl

cases in Periyar. But since the phenomenon
is much more widespread in North Arcot
Ambedkar. with nine out of 20 blocks
reporting Fl as per PHC records, it is difficult
to understand how no case of Fl came into
the sample of the survey.

Caste Factor

in 1986 when the practice of female
infanticide in Madurai district ofTamil Nadu
first received major media attention, the focus
was on the caste group known as ‘piramalai
kallars’. It was generally held at that time
that the practice of female infanticide was
for all practical purposes confined to the
piramalai kallars. Later, in 1992, whenfemale
infanticide was found to be widespread in
Salem district, the ‘gounder’ community was
considered to be the one practising it, and
it was believed by many that the practice did
not exist among other castes. Our survey
results - and the study of 3,000 respondent
households where female infanticide had
occurred in 1994 or 1995 - show a somewhat
different and alarming picture.
While the survey data has not yet been
completely analysed, it is abundantly clear
that the practice of female infanticide is not
confined cither to piramalai kallars in Madurai
district or to gounders in Salem. It has spread
to many castes. Data from one district alone
- Dindigul (now ’Mannar Thirumalai’) show occurrence of female infanticide in 35
(self-ascribed) caste groups. Further, the
practice seems to be widespread among the
poorer and socially disadvantaged
communities includingthcvars, vanniarsand
scheduled castes. For instance, of 124 cases
of female infanticide in Dindigul health unit
district, as many as 82 or slightly over twothirds. were accounted for by the piramalai
kallar.othcrkallar.thcvar.parayarandpallar
households. Scheduled caste households
belonging to the pallar and parayar groups
accounted lor 46 of these deaths or around
three-eighths of all female infanticide deaths

Table 11: A Comparison of ‘Female Infanticide Rates' DPH Survey 1996 and
PHC Records. 1995
No of Female Infanticide [>caihs
Female Infanticide Rale = --------------------------------------------No of Female infant Dcalhv

a

KX>

DPII Survey 1996

I’HC Daia 1995

Dharmapuri
Madurai
Salem
Tiruvannamalai Sambuvarayar
Dindigu)
Villuppuram Rainasamy
North Arcot Ainbcdkar

59.42
53.85
33.33*
8.57
20.74
0.75
0.00

Periyar

. o.o

Karur
Tiruchirappalli

9.89

50.48
36.37
42.70
0.14
16.35
1.23
16.28
10.53
5.79
2.00

District

0.83

Table 12: Distribution of Female Infanticide Deaths m Paritt. Select Health Unft
Disikicts, 1995

Health Unit District

Number of Female Infanticide Deaths by Female Parity
I
II
III and Higher
Total

Dhannapun
Madurai
Penyakulatn

27

April 26. 1997

l’

22

326
11
232

695 .
44
253

1048
56
507

WS-27

I.

!

I

J
.!■

I

i
i

I

t

r.

l

in Dindigul health unit district. Similarly, in
Salem a'nd Dharmapuri districts, vanniar and
scheduled caste households are al so practising
female infanticide. Data from Salem health
unit district’s records for 1994 and 1995
show that vanniar households account for
nearly half of all Fl deaths. The other castes
accounting for a sizeable number and
proportion of FI deaths include various SC
groups and gounders. The SC groups and
the gounders account for around 10 per cent
each of all FI deaths. It would not be incorrect
to conclude that while the piramalai kallars
and gounders in their respective areas of
numerical and social dominance may have
initialed the practice of female infanticide,
it now appears to cut across castes.
Nevertheless, it is also very likely the case
that the practice of female infanticide by the
dominant peasanl/landlord caste of the local
community served to legitimise and provide
social sanction to the practice, and contribute
substantially to its spread among all castes.
The value system of the dominant peasant/
landlord caste of the region, and the norms
of ritual expenditure patterns established by
them also raise, through pressures for
emulation, the perceived cost of bringing up
female infants for poorer members of the
dominant caste in particular, and forall castes
in general.
A qucsuontlial arises with regard to female
infanticide is whether birth order inlluences
the chance of survival of the female infant.
Some indicative evidence from the survey
of respondents I rom households where female
infanticide had occurred in 1995 is presented
in Table 12. Ideally, one would want to look
at the ratio of female infanticide deaths to
female births for each parity. The data
available with us has not yet been fully
analysed in this regard. However, given that
I he number of births would typically decrease
with birth order, some general inferences
seem to follow reasonably from the data in
f.iblc 10 which pertain to three health unit
districts lor whichthc data has been analysed.
The first female infant is. in a majority of
ca-.cs, not a victimof female inlaniK ide even
in these high Fl HUDs. although there arc
instances when it is. I he second female
infant has a much greater chance ol escaping
infanticide in Madurai HUD than she docs
in I'eriyakulam and Dharmapuiai HUDs.
While the third female infant is at much
greater risk than the first in all three HUDs.
both the second and third seem to be equally
at risk in I’eriyakulam. In Madurai and
Dharmapuri, on the other hand, the third
female infant runs a much higher risk of
being a victim of infanticide than the second.
Gi \ en that the population sizes of these H UDs
arc not widely different, one may not be
wiong in inferring that female infants face
the highest risk of death i n Dharmapuri HUD,
closely followed by Periyakulam HUD.

WS-2X

Concluding Remarks
We have so far confined ourselves to
presenting a detailed statistical picture of the
incidence of female infanticide in Tamil
Nadu, relying primarily on the PHC records
for 1995, a statewide sample survey carried
out by the directorate of public health in
1996 January-March, and field investigations.
These data confirm the widespread of the
horrifying phenomenon of Fl, and point to
a clearly recognisable core region, and a belt
running south to north along the western half
of the stale: four districts at the core, three
more as part of lhe belt, and most disturbing,
an expanding periphery of nine districts. '
While our exposition thus far has clearly
established these points of fact, a com­
prehensive analysis of the phenomenon is
beyond lhe limited objective of this paper.
Notes
1 While Kerala had an incredibly low IMR of
16. Punjab and Maharashtra with IMRs of 54
and 55 respectively did marginally belter than
Tamil Nadu, according to SRS provisional
estimates of 1995.
2 The State Action Plan for the Child in Tamil
Nadu in 1994 listed elimination of female
infanticide explicitly as a policy objective.
3 The PHC data appear, in general, to under­
estimate IMR. Thus, al the state level, for 1995
SRS gives a rural IMR of 61 (provisional), the

1996 sample survey yields 54.9 and the PHC
data a figure of 40.5. However, the under­
estimation appears to be fairly consistent across
districts. The survey-based IMR figures arc
significantly higher than PHC-bascd figures
for all districts.
4 One point may be noted here. Even though the
survey reports a high IMR of 78.2. the rcportec
male IMR at 87.0 is significantly higher
than the female IMR at 68.6. Clearly.
Ramanathapuram is not a district where female
infanticide is being practised.
References

Athreya. V B and Sheela Rani Chunkalh (1996 i
’Fighting Female Infanticide’. The Hindii
Madras, March 17.
Clark. A (1983): ‘Limitations on Female Lift
Chances in Rural Central Gujarat’. The India/.
Ecanomic and Social History Review, Vol 20
No 1. pp 1-25.
George. Sabu. Rajaratnam Abel and B D Mille:
(1992): 'Female Infanticide in Rural Soul;.
India’, Economic and Political Weekly
May 10. pp 1153-56.
Hausfatcr, Glen and Sarah Blaffcr Hrdy (cd
(1994): Infanticide: Comparative And
Evolutionary Approaches, Aldine Publishing
Company. New York.
Panigrahi, Lalita (1972): British Social Polics
and Female Infanticide.
Viswa Nath (1973): ’Female Infanticide and the
Lewa Kanbis of Gujarat in the Nineteenth
Century’. The Indian Economic and Smm.
Hixtory Review. Vol 10. N<» 4. pp 3K6-4(U

REVIEW OF WOMEN STUDIES
October 26. 1996

Valuing Work: Time as a Measure

—Devaki Jain

Measurement of Gender Differences Using
Anthropometry

—Anuradha Khali Raji van

Towards Gender-Aware Data Systems: Indian
l-.x pencncc

Gender-Related Development Index for Indian States:
Methodological Issues
Recasting Indices for Developing Countries:
A Gender Empowerment Measure
Critique ol Gender Development Index
Towards an Alternative

—Mukiii Mukhrijt c
— A' Srrta Rrahhu.
P C Saikcr. zl Rudha

—Aa\ha Ka/mi Mchla

—Indira Hirway, Darshini Mahadevia

'Die Review of Women Studies appears twice yearly as a supplement to the last
issues of April and October. Earlier issues have locused on: Women and Science.
(April 1996): Women’s Rights and Social Change (October 1995); Gender Issues
in Theory and Practice (April 1995)’. Women’s Movement in Third World (October
1994); Gender and Structural Adjustment (April 1994), Women and Public Space
(October 1993); Community. State and Women’s Agency (April 1993).
For copies write to
Circulation Manager
Economic and Political Weekly
Hitkari House, 284, Shahid Bhagatsingh Road,
Mumbai 400 001

Economic and Political Weekly

April 26, 199-

Vxi v\ - s

CAMPAIGN AGAINST SEX SELECTIVE ABORTION
11, Kamala 2nd Street, Chinna Chokkikulam, Madurai 625 002,

Telefax: 0452 - 2530486; 2534762, e-mail: sirdmdu@hotmail.3om

State-level Consultation on Role of Doctors in Halting the
Declining Child Sex Ratio
26th April, 2003, Chennai
IfCotetflbu (paCace, 926, Poonamatfee ffigli poacf, Chennai 600 084.
<Ph: 044 26412222; 26481497

Inaugural Session - 10.00 a.m.
Chairperson: Dr M.Balasubramaniam MDDV, President, Medical Council ofIndia
Welcome

Ms P.Phavalam, Convenor, CASSA

Perspectives

Dr Sabu M.George, Researcher

Inaugural and Key note

Dr Sundaravalli MD, DGO,

Address

Dean, Institute of Obstetric and Gynaecology

Special Address
Dr V.Vasanthi Devi, Chairperson,
Tamil Nadu State Commission for Women

Dr Vijayalakshmi MD
Director ofMedical Education - Schemes

Dr Cynthia Alexander MD., DGO

Ms Jeyanthi Natarajan

Gynaecologist

Former MP

Session - II : 11 a.m.
Chairperson ; Dr C.R. Soman, MD, MSc (Lon), MSc
Chairman, Health Action by People

Status and Reasons for Declining Child Sex Ratio
Initiating Discussion
Dr Jeyam Kannan MBBS., DCH

Dr Sabu M.George

Vijaya Health Centre

Researcher

Ms Mina Swaminathan,

Ms P.Phavalam

Director, ACCESS

Convenor, Campaign Against Sex Selective
Abortion

Co-convenor : No. 10, Thomas Nagar, Little Mount, Saidapet, Chennai-600 015
Ph: 044 -2235 35 03 Fax: 044 -2235 59 05, E-mail: hrf(d)md3.vsnLnet,in /hrftflbdweb.com

!• If<d

>

II

I

Session - III : 12 noon
Chairperson: Dr. Sabu George
Review of PNDT Act
Initiating Discussion

Dr Raman

Advo A.Gandimathi

Director, Medical and Rural Health Services

Campaign Against Sex Selective A bortion

Advo Jesurethinam
Director, Law Trust

Session - IV : 12.30 p.m.
Chairperson: Dr C.S. Rex Sargunam, MD, DCH
Retd Director Institute oj Child Health
<

Technology - Medical Ethics - Female Feticide
Initiating Discussion
Dr Thomas George, MB.D Ortho
Dr. Sanjay Nagral
Jaslok Hospital

Orthopaedic Surgeon, Railway Hospital

Dr J. Amalorpavanathan, MS, MCH
Vascular Surgeon, Vijaya Hospital

Dr S. Janaki MD, DGO
Medical Superintendent, Voluntary Health
Services.

Dr K. Devaki MBBS, DMRD

Dr Amuthan
Sonologist, Royapettah Govt Hospital

Devaki Scans

Session - V : 1.30 p.m.
Chairperson :Ms Mythili Sivaraman, National Vice President, AIDWA

Role of Doctors in Halting the Declining Child Sex Ratio

Initiating Discussion
Dr. Sanjay Nagral
Jaslok Hospital

Dr C.R. Soman, MD, MSc (Lon), MSc
Chairman, Health Action by People

Mr Jeeva

Dr Jeyagowri MD., DGO

Director, SIRD

Senior Civil Surgeon, Tamilnadu Govt Service

Resolutions : 3.00 p.m
Campaign Against Sex Selective Abortion (CASSA) is a state-level
coalition formed in 1998 consisting of social action groups, women’s
organisations, human rights groups, advocates, educationists,
research institutions and professionals from various fields including
doctors for the purpose of stopping the misuse of sex selective
technologies and techniques in medical practices and implementing a
multi-pronged strategy for preventing and halting the declining sex
ratio in Tamil Nadu.

1

I

Executive Summary of Report on
Sex Selective Abortion in the States of Gujarat and Haryana:
Some Empirical Evidence
Gujarat and Haryana Research Teams
Gujarat Institute of Development Research, Ahmedabad

In the context of fairly widespread practice of female-selective abortions in the states of
Haryana and Gujarat, this field based qualitative study examines the issues around this
practice from the perspective of women who undergo abortions and what compels them
to resort to abortions, who in the family really decides about resorting to abortion, and the
interlinkages of sex-selective abortion and decline in fertility. Does the desire for fewer
children compel parents to produce children of the sex that they want and regulate their
fertility behaviour accordingly?
From the data on pregnancy histories collected from women in both the states, including
the outcome of the pregnancy and sex of the live births, sex ratio of all live births by birth
order as well as the sex ratio of the last birth were calculated to understand at what stage
in family formation the couples were resorting to sex selective abortion. The sex ratios
were also calculated by some of the background characteristics of women such as age,
level of education, work status, caste and whether the family owns land to enhance our
understanding of who resorts to this practice.

In both the states, the preponderance of male children increased as the birth order
increased. Further, the preponderance of boys among the second and the third child was
much greater for women who were educated beyond primary level, women who were not
engaged in any economic activity or who reported themselves as housewives, women
who belonged to upper castes and those whose families were landed. The focus group
discussions with women from diverse socio-economic and educational groups also
substantiated this finding. Majority of the women accepted the outcome of the first
pregnancy - whether it was a boy or a girl. However, in the even of the first child being a
daughter, the upper caste women were overtly or covertly pressurized to ensure that the
second and or third child was a boy and take appropriate measures. Although this
pressure was much less among the lower castes, many among them have started either
emulating the women from the upper castes.

Further, the sex ratio of last births had a stronger preponderance of boys than the sex ratio
of all other births, with more than twice as many boys as girls. This points to a strong
influence of gender preference on reproductive behavior as well as the desire for few
daughters in the presence of dowry practices. Women of all social groups in both the
states indicated that if the first born child was a daughter, then they would try to find out
the sex of the next child, keep it if it is a boy and abort if it is a girl. Women knew where
to go for sex determination tests, how much they cost, etc. They were also aware that
such tests were not done in public hospitals but were done in private facilities, which also
provided abortion services. Women could also describe the sex determination procedure
quite accurately.

The study points to a pervasive collusion of culture or social norms and technology on
the one hand and internalization of values placed on sons to such an extent that even
when they say that daughters take better care of parents or are more emotionally attached
to the mothers, their statements have a ring of hollowness. Evidently, the shift to small
family size is not accompanied by a shift in the economic and social pressures to have
sons and avoid daughters. Government legislation against the use of ultrasound for sex
detection has only driven it underground and raised the cost but it is extensively available
and used for sex detection. The cost of the test and related abortion is still affordable
because it is much lower than the cost of providing dowry and other life long
presentations to a daughter.

WK"? •

Situational Analysis of Abortion
Services in Rajasthan:
Major Findings
Action Research & Training for Health,
Udaipur

Data collection tools and coverage

Checklist
(n=86)
Administrator
(n=82)

Private

Government

40

46 (39 PHC/CHC;
4 PH/ Med C, 3 Other)
42 (35 PHC/CHC;
4 PH/ Med C, 3 Other)
30 (15 PHC/CHC;
12 PH/ Med C, 3 Other)
________ 18________
283

40

Provider
(n=69)

39

ISM (n=63)
Informal

45
335

(n°618)

1

Functional status of formal facilities
Type of facility

Total (n=82) Functional (n=61)

Public facilities:
- PHC/CHC
- DH/MC/PPC/SH
- Other
Private facilities:
- Certified
- Uncertified

42
35
3
4
40
21
19

22
15
3
4
39
20
19

Availability of personnel at facilities

Any doctor prov. abortions
Gynecologist
Fulltime gyncc
Fulltime MDBS
Other abor providers
Any anesthetist attached
Registered nurses
At least female provider

Public
(n=42)
52%
24%
24%
33%
9.5%
21%
100%
41%

Private
(n=40)
97%
70%
48%
35%
18%
88%
70%
92%

2

Certification status of private facilities
• Certified
- With certified provider
- No certified provider
• Uncertified
- With certified provider
- No certified provider

District 1
1

District 2
20

0
1

20
0

6

13

0

7

6

6

6
19

8
9

Government facilities
- With certified provider
- No certified provider

Problems encountered in certification
(certified facilities, n=21)
% having any difficulty:
Types of problems:
- Long tedious process
- Complicated paperwork
- Repeated demands for information:

12

12
5
1

Reason why facility is not certified (n=19)
- Did not apply
- Applied but not yet cleared:

jj
8

3

Reporting by functional public+certified private
facilities (n= 42)
- Report all MTPs:
31
- Report some MTPs:
2
- Report none:
9
Consent (n= 61 functional facilities)
• Consent taken:
58
Person whose consent is taken
• Woman alone:
9
• Woman and husband:
17
Woman & family members/ accompanying person:
31
* Cthers, but not woman herself:
j

Circumstances under which facilities
provide abortions
• Woman coming alone

10%
• Comes with friend, without family member:
43%
• Unmarried woman:

49%

• Widow/ separated:

56%
57%

• Married but no children:

4

Facility infrastructure
Govt
• Waiting area present:
80.4%
• Toilets with water facility: 45.6%
• Visual privacy in consulting room
56.5
• Operation room dust free
45.4%
• Torch in procedure room:
30.3%
• Adjustable focus lamp
15.1%
• Adequate water supply
57.6%

Private
97.5%
100%

95%
100%
692%
65.4%
962%

Observation of OT and equipment

OT/ Procedure room:
Anesthesia equipment:
Sterilisation equipment:
MTP instruments/ eqpmt

Govt
(46)

Pvt
(40)

Total

33
30
35
28

27
27
27
27

60
57
62
55

(86)

5

Availability of equipment related to MTP
MTP eqpt.______GOvt

py;
(n= 27)

Total
(n= 55)

15
25
27

19
40
48

Anesthesia & Sterilisation equipment
Boyle’s apparatus
20%
89%
Oxygen cylinder
77%
93%
Autoclave
94%
96%

53%
84%
95%

(n= 28)

Complete set MV A 4
Complete set EVA 15
Complete set D&C 21

Service provision at functional facilities
Gestation up to which Pregnancy is terminated (n= 61)
Public (n=22)
Up to 8 wks
Up to 12 wks
Up to 20 wks
Beyond 20 wks

100%
82%
36%
9%

Private (n= 39)

100%
87%
41%
03%

6

Sterilisation/ infection prevention
• Instruments are sterilised as per standards 87%
• Cannulae are sterilised as per standards
• Decontamination followed:

61%
36%

• Disposal of blood and POC in open garbage: 36%

Number of MTPs conducted in functional
facilities per month (n=61)
• Upto 12 wks
• 13-20 wks
• >20 wks

Public (n=22)
7

1
0.02

Private (n= 39)
15
1.4
0.1

Had to postpone services at least once in last 3 mo
- 73% ------ 10%
Most common reasons for postponing
• Provider not there
• Lack of Electricity /water
• Equipment out of order

7

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I

Ability to handle emergencies
Public
(22)
91 %
82%

Overnight staying facility
Receive emergency cases
Doctor available at night to see emergencies

Private
(39)
87%
100%

60%
Avg no. of complications seen in the last 3 months

Management of abortion complications
In house mgmt of excessive bleeding
In house mgmt of perforation

72%

1.6

3.1

77%
40%

92%
56%

Provider characteristics
Pub(n=30)

I

Female
Mean age yrs
MTP trained
MS Gyne/ DGO
MBBS
MS Surgery/MD
Not MTP trained

43%
39
19
12
3
3
11

Pvt (n= 39) Total (n= 69)

87%
45
28
23
4
1
11

68%
42
47
35
7
4
22

8.

MTP training
Type of procedures in which providers received training
(n=47 formally trained)
• MVA
57%
•EVA
72%
• D&C
89%
•D&E
85%
• Extra amniotic method
75%

Techniques used by providers for 1st trimester abortions
Formally trained (n=47)
MVA
14%
EVA
41%
D&C
43%
D&E
7%
Medical methods
11%

Untrained (n=22)
0%
21%
79%
5%
0%

Techniques used for II trimester abortions (for those
who perform II trim abortions)
Extra-amniotic
D&E/D&C
Medical methods

54%
17%%
46%

25%
88%
0%

9

Pain control methods

1st trim abortions (9-12 wks)
MTP trained (n=47) Untrained (n=22)
- GA
55%
26%
- Sedation
- Analgesia

66%

57%
5%

68%
68%
0

4.2%
13%
46%
50%

13%
38%
38%
38%

Ilnd trim abortions
- GA
- Sedation
- Analgesia
- No need

Average cost of abortion
Public facilities
< 12 weeks
13-20 wks

195
317

Max COSt (Rupees)
457
575

Private facilities
< 12 wks
13-20 WKS

Min cost
541
1144

_____ Max cost
724
1681

Total__________
<12 WKS
13-20 WKS

Min cost
414
918

Max cost
753
1380

Min cost

10

Contraceptive counseling
• % giving contraceptive counseling
Timing of counseling before procedure

• Insistence on contraceptive methods:

97%
70%
80%

Dealing with women seeking repeat abortion:
• Refuse MTP
• If agrees for steri, then do MTP:

• Do it if she agrees to use a contraceptive:
• Perform MTP
• Not faced such a situation:
• Other

22%
22%
23%
20%
12%
3%

11

i

Executive Summary - DR ALEX GEORGE

ABORTION PROVIDER STUDY: MADHYA PRADESH
METmDOLOGY
Objectives
The study intends to understand and analyse issues related to the provision of abortion services
in public and private sectors.
> Management of abortion services including management of complications.
> Technologies used
> Registration, training and certification
> Availability, technical competence, training needs and current training facilities/
programmes for abortion care providers
> Utilisation of facilities
> Adequacy/ appropriateness of the MTP Act from the providers perspective
> Costing and Finance related issues

Sampling : Selection of Districts
For each district the values ofsix variables- sex ratio, percentage ofinstitutional deliveries,
female IMR, female literacy, total fertility rate (TFR) and couple protection rate (CPR) were
identified and the districts were rankedfor each variable. The ranks were added up to arrive at a
composite score for each district, and the district with die lowest rank scored the rank one and so
on. From the ranked districts, one district each from the top and the bottom quartiles were selected,
excluding the top and the bottom ranked districts as outliers. District of Ujjain as second most
developed and district of Sidhi as second least developed were selected from the highest and the
lowest quartiles. Some new districts and blocks were created in M P in the last few years and
hence the selection of districts were restricted to the old districts.

Selection of Blocks
The blocks were first ranked according to their urban population percentage. The ranked
blocks were then divided into three groups, one group that was closest to the average urbanisation
percentage of the district, another group, which had blocks above the district urbanisation
percentage and the third group below the average level of urbanisation. In the district of Ujjain
with an urbanisation percentage of 38.74, Ujjain block with 76.40% urbanisation, was selected as
the block with above average urbanisation, Kachrod block with 39.35% urbanisation as the block
with average urbanisation and the Tarana block with 9.87% urbanisation was.selected as the block
with below average urbanisation. Similarly in the district of Sidhi with an urbanisation percentage
of 14.28, Baidhan with 44.32% was selected as the above average block, Gopanbandhas block
with 19.72% as the block closest to average urbanisation and Rampur Naikin with 8.57%
urbanisation was selected as the below average block.

Abortion Provider study: Madhya Pradesh
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Sample Size, Sample Selection and Mapping
In each selected block all the public providers/institutions like Primary Health Centres
(PHC), Community Health Centres (CHCs), civil hospitals, District hospitals and hospitals of
Public Sector Undertakings and private formal providers both registered and unregistered were
mapped using a listing form. The listing form recorded a few basic characteristics of the facility
and the willingness to participate in the study. None of the PHCs in both the districts were
providing abortion service.

For listing the providers, help from the CMOs of both districts, superintendents of district
hospitals, nurses, medical representatives, chemists, hospitals, local journalists, and other
concerned people were utilised. A detailed map of each district and of selected blocks, which were
collected from the concerned Block Development Officers, were also utilised for the purpose.

Number of Mapped Facilities and Those who Agreed to
________ Participate by Facility Type and District______
____
Abortion Service Facility
Public__________
Private

State
Madhya
Pradesh

District 1
-Ujjain__
District 2
Sid hi
Total

Informal

Number who
were providing
the services and
agreed to
participate

Total
Identified

Number who
agreed to
participate

Total
Identified

Number who
agreed to
participate

11

6

42

25

75

75

22

5

26

26

95

95

33

11

68

51

170

170

Total
Identified

Out of the 33 identified public facilities, which were supposed to provide abortion service
onW 1 1 were providing the service. They agreed to co - operate with the study and have got
included in the sample. Out of the 68 identified private formal facilities, in both the districts
together only 51 co -operated with the study, and got included in the sample. Non co -operation
of private providers was the highest in Ujjain District, which had a concentration of organised
providers in the city who refrained to participate. Of the 42 private providers only 26 participated
in the study. In Sidhi district, the total number of private formal providers was small. Since they
were probably less organised also, all the 26 formal private providers/institutions co-operated and
got included in the sample.
Out of 4 PIICs in Ujjain, none were providing abortion services. Of the 15 PHCs in Sidhi
too none were giving abortion services. Out of the 4 CHCs in Sidhi 2 were providing the services.
All the 3 civil hospitals in Ujjain were providing the service. Both the district hospitals were also
providing the service.

Since it was found during the mapping that informal providers constituted the major chunk
of abortion providers in rural areas and even in some urban areas of both districts, we included a
substantial number of informal providers also in the study. Each nook and corner of the selected
Abortion Provider study: Madhya Pradesh
X

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blocks m two districts was explored to list the informal/traditional providers Detailed maps of the
both districts were also utilized for the mapping purpose. Seventy five informal providers are
included from Ujjain District and 95 from Sidhi District.

Tools Used and Data Collection
The administration schedule addressed the administrator or the provider in charge of him /
her. The provider schedule concerned the providers of abortion service in the facility and were
administered to them. Except in the case of five facilities, the facility assessment data was
collected through direct observation by the investigators and from the administrator / provider in
charge in the case 46 facilities which agreed to provide this information. The schedule for informal
provider addressed the issues of informal provision and was administered to such providers. The
information for all schedules was collected by investigators through direct interviews. The
researchers who were on the field along with them supervised investigators. The researchers have
accompanied investigators and also conducted made sure that the investigators have interviewed
the concerned administrators/ providers and conducted more than random checking on the field.
All the forms checked in the evening every day and gaps or inadequacies in them were corrected
with further visits to the facilities/ providers.

Selection and Training of Investigators
Out of the six investigators in team, three were postgraduates in Social Work from Nagpur
University, with some field experience. They were helpful in dealing with the doctors and
collecting data, which had more social and economic bearing. Two female investigators were
nurses with Diploma in General Nursing from Sulthania Ladies hospital, Bhopal The nurses
assisted in collecting data on medico-technical aspects of abortion services, particularly in
observing the equipment and instruments and filling up the Checklist. For local support in the
sample districts, two social activists from Bharat Cyan Vigyan Samiti (BGVS), Bhopal were
selected who had contacts in the respective districts were also included in the investigators team
and trained.
Three day residential training was given to the investigators, prior to the fieldwork in each
district using common guidelines and instruction manual. A detailed explanation of social,
economic, medical, legal and ethical aspects of all the questions was provided during the training.
The Project Co-ordinator for MP, explained the social, legal and ethical aspects of abortion, which
were also implied in the schedules used for data collection. A Gynaecologist explained the medical
and surgical processes and terminologies mentioned in the protocols, particularly the methods of
abortion, medicines used for abortion, post abortion complications, various MTP instruments, their
usage etc to the investigators. Later the investigators, with the Gynaecologist and the researchers
visited a Government hospital in Bhopal, to see for themselves the physical infrastructure, M TP
equipment, instruments, amenities and Operation Theatre used for abortion. Here also the
gynaecologist demonstrated and explained the functioning of various equipment and instruments.
This training programme, winch was initially conducted for the fieldwork in Sidhi district, was
repeated before the fieldwork in Ujjain also.

Abortion Provider study Madhya Pradesh
X

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4

findings
Certification
There was a very low level of certification among the private facilities / providers in both
the districts. Only 36% ol facilities in Ujjain had either provider or site certified. Corresponding
percentage in Sidhi was as low as 8%. Sixty four percent and 77% of facilities / providers
respectively in each district had never tried for registration also. The mean time gap between
application and registration was 8.58 months for both the districts together and the mean number
of times application was refused was 2.73.

Reporting and Consent
All tiie public facilities and only 55% of the certified private facilities reported the MTP
cases to the Government. All public facilities and an almost equally high 92% of private facilities
took the consent of the women. Except in a little over one third of private institutions the consent
was written in all other institutions. Although as per the MTP Act only the women’s consent was
necessaiy for conducting abortions, no public institution did it so. Even among private institutions
only 2 % would do abortions with women’s consent alone. Abortion procedure was mentioned in
the consent forms of only 28% of private hospitals and higher 64% of public hospitals.
Physical Facilities Available in Institutions
Place in Hospitals where MTP was done
Even among the District and civil hospitals and other public facilities which are supposed
to have relatively better tacilities, 11% abortions were conducted in the out patient department.
Twenty thieo percent of uncertified private facilities also conducted abortions in their consulting
room only. Eleven percent of District, civil and other public hospitals conducted abortion in the
procedure room. Among the private facilities also 18% of certified and 27 % of uncertified
facilities conducted abortions in the procedure room. It causes concent as to how the requirements
of equipment, instruments and that of privacy could be met when abortion are conducted in OPDs
and consulting rooms.

Privacy
Eighty nine percent of district, civil and other public hospitals had visual and auditory
privacy in the consulting room, while it was 100% among certified private facilities. In the case of
uncertified private facilities the percentage for the two variables was relatively less at 67% and
50% respectively.

Equipment / Instruments
It was possible to observe the abortion related equipment and instruments in all the public
institutions. But only a relatively low 89% of private institutions who co-operated with the study
allowed us to do so.
Sixty seven percent of District/Civil/other public hospitals and certified private facilities
had electric suction machine (ESM), whereas only 33% of not certified private facilities had ESM.
Eighty nine percent of district, civil and other public hospitals and 67% of certified private
hospitals had MVA syringe. Only 78% of district, civil and other public hospitals and 67% of
certified private facilities had at least 3 different sizes of MVA cannulae. The availability of MVA

Abortion Provider study: Madhya Pradesh
X

5
syringe, cannulac and adapters among the uncertified private facilities were 67%, 67% and 56%
respectively. Among the CHCs only 50% had the above mentioned equipment.
Fifty percent of CHCs had shadow less OT lamp while none of them had ad justable focus
lamp. Shadow less O f lamp was available in 67% percent of Dist/ Civil and other public hospitals
and 73% percent of certified private facilities while only 21% of uncertified private facilities were
having it. Eighty nine percent of other public facilities and ninety one percent of certified private
facilities had adjustable focus lamp, while 50% of the uncertified private facilities also had it.

All certified private facilities and CHCs had Sim’s/ Cusco’s speculum, Tenaculum/
Volsellum, Ovum forceps and Uterine curette. The availability of these instruments among the
7istrict/Civil/ and other public hospitals and certified as well as uncertified private hospitals were
on the higher side: above 85%. Dilator set was available in 50% of CHCs and 78% of district, civil
and other public hospitals, while 67% of certified private facilities had the set. Compared to other
categories 91% of uncertified private facilities had complete set of Dilators.
A higher percentage of public and certified private hospitals had most of the anaesthetic
equipment. Among the district and other public hospitals, 89% had Oxygen cylinders, 78% had
Boyles appaiatus as well as laryngoscope. 1 he first two of these equipment were not available in
both the CHCs. Not even half of the non-certified providers were having either Oxygen cylinders,
Boyles apparatus or laryngoscope.
The public and certified private hospitals showed a higher percentage of availability of
various sterilization equipment such as Steam sterilizers, formalin chambers <<: autoclaves. The
corresponding percentages were low for the non certified facilities.

Maintenance of Equipment
Only 10% of the institutions had taken annual maintenance contracts. It was highest among
'ie District, Civil and other public hospitals with 33% and lowest at 5% among the non-certified
providers.
Availability of Drugs
Among the drugs used for inducing abortion or cervical priming, Ethcrydinc was available
in only up to or less than 50% hospitals in die four categories of hospitals. Its availability was the
lowest at 29% in private non-certified hospitals and highest in the CHCs at 50%. But Prostaglandin
injection was not available at 100% of CHCs. In |he Dist/ Civil and other public hospitals,
Prostaglandin was available at 78% institutions. It was also available in an equal number of
certified private institutions. At the same time its availability dropped to only 43% in non-certified
private institutions. Only 44% of even Dist/ Civil and other public hospitals had prostaglandin gel.
Its availability was still less at 33% in the case of non-certified private institutions. In certified
private institutions however 89% were having it. In the case of Oxytocin injection except among
the CHCs, where only 50% had it, the other three categories Viz. Dist/Civil and,other public
hospitals and the private institutions had a higher availability ranging from 89% to 1 00%.

Family Planning Devices
I emporary devices of FP such as Oral Pills and Condoms were available in both the CHCs
in the sample, while IUD was available only in 50% of them. Condoms were available at 100% of
district civil and other public hospitals, while 89% of them had Oral Pills & IUDs. The pattern
Abortion Provider study. Madhya Pradesh
X

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6

loimd in (he di’ihict, civil and oilier public hoapitala was also seen in thoccilillcd piivalo facilities.
But non-certified institutions showed relatively a low availability of all these devices. Tubectomy
and IUD were the methods insisted by 71% and 74% of formally trained providers. On the
contrary, only 50% of not formally trained providers insisted on Tubectomy.

Contraceptive Counselling
All the 42 formally trained providers (100%) offered contraceptive counselling, while this
percentage was slightly less at 89% with the not formally trained providers. Majority i.e. 60% of
formally trained providers offered contraceptive counselling before the procedure, while 46% of
not formally trained also did so. As high as 95% of formally trained providers insisted on the
method while a slightly less 77% of not formally trained providers also did insist on it.

Availability of Service Providers & Anaesthetists
There were at least one or more full time gynaecologist/ MD/ MS/ DNB in Gynaecology &
Obstetrics or DGO at public facilities and 45% certified private institutions. Only 15% of
uncertified facilities had full time gynaecologists. A small 9% & 13% of certified and non certified
private facilities had them visiting on specific days. Only 18% of uncertified facilities had full time
MBBS doctors.

As high as 81% of facilities did not have an anaesthetist either as full time, on call or
attending part time. It could be that the surgeons themselves were functioning as anaesthetists.
Even among the public institutions only 36% had full time anaesthetists

Provider Characteristics
There were 27% (19) public providers and 73% (52) private providers in the sample
Among them only 34% were MD/MS/ DNB in Gynaecology & Obstetrics or were DGOs. Trained
prdviders with MBBS or MD/ MS in other branches were also only 16%.
On an average the mean number of years of abortion practice of the providers was 13 years.
The mean age of the providers was 42 years, with a range of 24 - 65 years. Out of the 68 providers
who could be interviewed for the study, 51.5% were females slightly more than the male
percentage of 48.5. This is because ofa higher number of lady providers who co-operated from the
developed city of Ujjain and cannot be taken as indicative of the gender distribution of abortion
providers in MP. Twentythree out of thirtyfour providers in the study from Ujjain were women.
Training
A very high 77% of the public providers were either MS / MS/ DNB in Obstetrics &
Gynaecology or DGOs. Among the private formally trained providers only 44% had such
qualifications. The presence of large number of highly qualified providers in the public sector
could be the reason for more referrals from the private to the public sector in the case of
complications.

Training in MTP is provided only at five medical colleges in MP viz., Bhopal, Indore,
Gwalior, Jabalpur and Rewa and eight district hospitals at Bhopal, Guna, Barwani, Jabalpur, Satna’
Sagar, Mandsaur and Ujjain.

Abortion Provider study: Madhya Pradesh

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7
Abortion Done by Gestations

Sixtynine percent of the abortions conducted in CHCs were up to 12 weeks. Twenty percent of
them were from 12-20 weeks and the rest 10% were for above 20 weeks. On the whole 59
abortions were conducted in a month in die two CHCs. In tlie District, civil and the other public
hospitals 694 abortions were conducted in a month. Of them 69% were in the up to 12 weeks
category and 31% were in the 12-20 weeks category. There were no abortions conducted in this
group of hospitals for the above 20 week pregnancies. On the whole 210 and 1069 abortions were
conducted per month in the cer6tified and uncertified private facilities Among the certified
institutions, 79% of abortions conducted were of up to 12 weeks pregnancies, 21% belonged to 1220 weeks, while no abortions were conducted in the above 20 week category. In the non-certified
institutions 95% of the abortions conducted were in the up to 12 weeks category.

Functioning at Nights
82% public facilities were open at night, while only 55% of private facilities also did so. At
night doctors were however available only in 46% of public and a still less 41% of private
facilities.
Managing Complications
1 he percentage of institutions, which handled in-house, the complications ofabortion such
as Excessive Bleeding, Perforation due to Peritonitis, Septicaemia, shock and infection was
relatively higher in public than among private facilities. Referrals on developing complications and
referrals after stabilisation from private institutions ranged from 47% for shock to 59% for
septicaemia.

As regards management of post abortion complications, 82% of public institutions received
cases of incomplete abortions, while only 59% of private institutions did so. Cases of
Haemorrhage were taken in 73% of public institutions, while only 55% of private institutions
treated them.

Referral Patterns
I he four public facilities, which referred cases commonly, did so for 2nd trimester abortions
and medical risk cases. In the private sector 87% and 64% facilities respectively referred cases of
these two categories. A large 41% of private facilities which commonly referred abortion cases,
iclerrcd to the District / Civil or other public hospitals.
Techniques Used & Pain Control
For abortions up to 8 weeks many of the formally trained providers (38%) used D&C and
Manual Vacuum Aspiration (MV A). Several of the not formally trained (50%) providers also used
case
abortions between 9-12 weeks, large number of formally (rained providers
(45%) used D&C while 58% of not formally trained providers also used the same method.
Only 36% of formally trained providers and 15% of not formally trained providers were
conducting second trimester abortions. Majority of formally trained providers i.e. 53% used D&C
lor second trimester abortions. Intra Amniotic and Extra Amniotic methods were also used by a
small number of formal providers, 7.1% and 5% respectively.

Abortion Provider study: Madhya Pradesh
X

8

Pain Control Methods
To control the pain of abortions up to 8 weeks 93% of formally trained providers used
analgesics and sedatives, while local anaesthesia was used by 67% of them. The pattern was the
same with reduced percentage for the not formally trained providers also: 58% and 42%
respectively.
In the case of abortions of 9-12 weeks also 79% of formal providers used analgesics and
sedatives, while 67% used local anaesthesia. General anaesthesia was used by 14% of formally
trained providers. Half of the not formally trained providers also used analgesics and sedatives for
9 abortions of -12 weeks, while local anaesthesia was used by 42 % of them.
Analgesia & sedatives and General Anaesthesia were used for pain control for second
trimester abortion by majority of formally trained providers. The respective percentages for
formally trained providers were Analgesics & Sedatives 73% and General Anaesthesia 53%. While
75% of not formally trained providers also used analgesics, sedatives and local anaesthesia, all of
them said they used general anaesthesia.
It appeared that only few providers were conducting abortions above 20 weeks, which is
not legally sanctioned. Among the two formally trained providers who were doing abortions above
20 weeks, one was using local anaesthesia, while both used analgesics and sedatives. One provider
from among not formally trained providers who did such abortions also mentioned only local
anaesthesia for pain control.
Pre discharge Examination, Counselling & Follow Up Advice
General physical examination was conducted by a 98% of formally and by 81% of not
formally trained providers. Pelvic examination was done by 60% of formally trained providers,
while only 23% of not formally trained providers conducted it. Abdominal examination was
conducted by 45% of formally trained, while only 31% of not formally trained providers also did
it.
Pre & Post Abortion Counselling & Follow Up Advice
All formally Trained providers and 96% of not formally trained providers were providing
pre and post abortion counselling. Excessive bleeding, abdominal pain and vomiting were the
conditions for which follow up was advised by 95%, 91% & 71% of formal providers. Ninety six
percent of not formally trained providers advised follow up for excessive bleeding, while 81% of
them advised it for abdominal pain.

Access to Abortion Services
A. Logistic Access
82% of public and 91% private facilities were situated on the roadside or close to it. Bus service
was available to reach 91% of public and 69% of private facilities.
B. Economic Access
»
Cost of Services
Seven of the 11 public facilities charged an average maximum amount of Rs. 285 for
abortions of 12 week old pregnancies and 2 facilities charged an average maximum amount of
Rs.775 for abortions up to 20 weeks. The cost of abortion in private facilities for different
gestational periods was considerably higher. The average maximum cost of MTP service in private
sector for up tol 2 weeks gestation and up to 20 weeks were Rs.559 and Rs. 1321 respectively. But

Abortion Provider study: Madhya Pradesh
X

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■

!

9
few of the uncertified private providers were ready to make MTP available for as low as Rs.30 to

Out of 51 private facilities only 3 were providing MTP service for above 20 weeks The
mean maximum cost of MTP for above 20 weeks in private facilities was Rs 1583 The range of
maximum cost in private sector varied from Rs. 1000 to Rs. 2250.
' ’
g
C. Gender Access
Facilities with Female Providers
n
t ?50/° °f publ'C facjlities were having at least one female abortion provider while 55% of
private facilities were not having even one woman providers.

Provision ofAbortion by Informal Providers
Profile of the Informal Providers Interviewed

sgsssssss
(1 IbTas 7hCtlt,°nern fOnnekd the majOr Chunk of informal providers in both districts' ie 67 47%

freatment of‘Delayed Periods’ by Informal Providers
of femate'mfoZ1

males accepted that Ly used instruments SS’/o oSle "f
a^0111011 Whi'e °niy 41 % °f
were successful in more than 50% of cases’whiled of femal ^''^7 claim.ed ,hat ,n.iect,ons
injections were successful
’
46/ of(emale mformal providers also said that
instruments, while 72%
mfoX^
,nSt1mmentS 46% of them ^ed sharp metallic
D&C for inducing abortion Thirtvnine and f
f
Wh°
,nstruments> were using Curette /
curette/D&C, Syring^XSvX Around .^ f°UF perCent ofma,e inf°™al providers also used
informal providers also used cathJer^nlmr" aZnmT"^
°fma'C and femak

..... '"c malc
was done using instruments
gestation period for which t^fema^ mfo^ I "

p'nod f~whid’

WeekS' CoiT“Pondmgly the mean
■WOof 1 -23 weeks. Both th.^ories8„t^toa^XTthZ^^Wi,h a

Abortion Provider study: Madhya Pradesh
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otxcxJki^ — pA>Mx

fWA - b=^ '

VaJ \ \

'

Foundation for Research in Health Systems, Ahmedabad
8"' May 2003

1

Draft Summary

Study on Availability and Accessibility of Abortion Care
By
Foundation for Research in Health Systems

(

(

)

)

’

The research project “Study on Availability and Accessibility of Abortion care” was conducted by
Foundation for Research in Health Services (FRHS), Ahmedabad, in two urban slums of Ahmedabad
in Gujarat State. Health Watch Trust, New Delhi sponsored the study.
Objective
The objective of the study was to understand the nature, distribution and quality of abortion services
accessed, and characteristics of and reasons for women seeking abortion services from approved /
recognised or from unlicensed and unqualified providers in two urban slums. The study aimed to
also look at women’s and health providers’ views on abortion related morbidity and mortality.
Site
One of the slums selected for the study, SLUM 1, has a network of service providers, both qualified
and unqualified, private, government and non-government clinics, and a tertiary care hospital run by
Municipal Corporation. The other, SLUM 2, on the outskirts of the city, at the time of the study was
without a tertiary care hospital and is 5 -6 Kms from government /municipal hospitals. As the study
was qualitative and focused on accessibility to services, it was decided to confine it to only slums.
This was based on the assumption that access to abortion services would not be as much a problem to
the more affluent classes.
Methodology
The data collection methodology consisted of qualitative techniques such as Focus Group
Discussions (FGDs) and in-depth interviews. Graduate female investigators were hired to carry out
the data collection. Instruments for in-depth interviews and FGDs, and consent forms for written or
verbal consent of respondents, were developed. After approval by the in-house Ethical committee of
FRHS, the instruments and consent forms were sent to Health Watch, New Delhi for their approval.
Flexibility about the order in which to use the two techniques was deliberately retained as the topic is
sensitive. It was felt that because of the sensitive nature of the topic, women might not be very
forthcoming in a group discussion in the early stages of the study. Also individual perceptions,
knowledge and practices regarding abortion service use were the focus of the study, and interviews
offered the possibility of studying these in detail.

The fieldwork was to start after receipt of their oral approval. However there were problems because
of the communal tension in the city. This resulted in having to change one of the selected slums to
another site with similar characteristics. Finally the fieldwork could begin only in second week of
February 2002. The study began with in-depth interviews. This being a qualitative study looking at
perspectives of seekers as well as providers, and not attempting to study prevalence, morbidity and
mortality rates, the sample was purposive. The plan was to cover 18 providers (including un­
qualified) and 60 women seekers of abortion in the study.

The help of the key informants, who were knowledgeable and prominent women from the locality,
was enlisted to approach women who had availed of abortion services. Snowballing technique was
also used to identify women for interviews. Service providers were not used at any stage as key
informants to identify abortion seekers, keeping in view the ethics of medical practice. Though the
key informants did list a few unmarried and single women opting for abortions of unwanted
pregnancy, they were not covered under this study because of the possibility of giving prominence to
an action undertaken or opted for in secrecy. All women were told about the purpose of the study and
assured that their names would not be mentioned. They were given the option of not participating as

Foundation for Research in Health Systems, Ahmedabad
8"1 May 2003

2

well as quitting midstream. It was also clarified that no specific benefit would be accrued out of
participation in the study.
In both slums the first woman was first contacted by the key informant to check whether she had any
objection to being interviewed. After that the research staff approached the woman and interviewed
her in complete privacy and with her oral consent. The next woman was identified with the help of
either the key informant or the woman herself. While not all abortions were with the knowledge of
all influential family members, not a single one was without some family support either. Therefore,
possibility of jeopardising confidentiality of the abortion was not a major threat the research team
faced.

Interviews of all women were conducted after taking their oral consent. In all 64 women were
interviewed, but 2 interviews were discarded as the history of abortion was not very clear despite
repeated checks. Initially it was planned to conduct interviews with women who had undergone at
least one abortion in the two years preceding the study. However, it was decided to increase the
reference period to 5 years as it was difficult to locate such cases within the study time line limited
by the communal tension in the city. Access to women was not a problem at all in SLUM 2 as they
were mainly from migrant families and looked forward to any initiative which they thought might at
a later date help them with their problems. They were given no incentives or promises by the
investigators to get their co-operation nor was any statement made to give them any false hopes. In
SLUM 1, the women were a little more circumspect and did not open up to the interviewers easily.
Help of the local NGO that has been running a clinic in the area for last two decades had to be taken.
Though not a single woman refused to give interview in both areas, within the first couple of days
the investigators realised that a second interview with the same woman might not be easy, so they
went in teams of two, and as far as possible covered all the required information in one sitting.
In case of interviews of health providers, it was decided to seek the help of key informants or women
who had availed of abortion services to identify the providers who according to them provided the
services, and then interview a representative sample. During the course of the study it was found that
none of the women in either of the slums listed any unqualified provider. Therefore, unqualified
providers were dropped from the sample. Also, though the government tertiary hospital is not located
in either of the slums, but women did report using the services there, we covered a gynaecologist
from that hospital and while the general practitioners, nurses and Dais did not conduct abortions,
they provided referral services to women coming to them and hence were included in the sample.
Throughout the study, confidentiality of information was maintained for all the respondents.

In all, the 18 health providers interviewed were private gynaecologists, medical officers in NGO
clinics, gynaecologists from municipal and government tertiary care hospitals, qualified general
practitioners, a nurse and two dais. Interviews were conducted in more than one sitting with
providers in case information on all the research questions was not forthcoming in one sitting.
Access to private gynaecologists, NGO medical officers and gynaecologist from the government
tertiary hospital was not a problem. The municipal corporation tertiary care hospital, followed a very
strict protocol before the research team could even get in touch with the gynaecologists. Personal
contacts within the hospital and corporation health system were utilized to make the hospital
authorities expedite the permission procedure.
By the time half the interviews were over, the investigators had developed enough rapport with
women in the community to conduct FGDs. FGDs were done for triangulation of findings of the
interviews as well as to get the general trend of perceptions and practices.

3

Foundation for Research in Health Systems, Ahmedabad
8,h May 2003
Main findings

Table 1: Slum characteristics
Area
Indicator
SLUM 2
SLUM 1
Outskirts
Close to city center
Location_____
No
Yes
In Corporation
limits________
40,000
70,000
Population
Migrant
tribals
Patels, Thakors
Predominant
_____ Rajputs_____
population
Not available
Available
Civic amenities
Dais
Abortion
Dais
Gen. Practitioners
Gen. Practitioners
services
Pvt. Gynaecologists Pvt. Gynaecologists
National NGO
Local NGO
CFPC
Tertiary care hosp.

Skim characteristics

SLUM 1 is inhabited mainly by
Patels, Thakores and Rajputs. It is
within Ahmedabad municipal limits,
is very close to the city centre and
has very good connectivity with rest
of the city. Most of the houses are
pucca and have all basic amenities
provided by the city municipal
corporation. The slum has a
population of about 70,000 served by
a large tertiary care municipal
hospital, and a national level
recognised non-government abortion
service facility. It has several
private practitioners including Dais
and a Comprehensive Family Planning Centre (CFPC) run by a non-government organisation.

SLUM 2 on the outskirts of the city has a population of about 40,000. It is inhabited mainly by
migrants from tribal community of Udaipur district in Rajasthan. The houses are mostly kuccha /
semi pucca and some of them receive water supply from the local panchayat. The slum is outside the
corporation limits, and does not have civic amenities. At the time of the study it had neither a tertiary
care hospital, nor a national or a local NGO run service facility. It had clinics of only two private
gynaecologists in the close vicinity and a clinic on the lines of a primary health centre run by the
local panchayat.
Characteristics of women in the sample

In all 62 women, 30 from
SLUM 1 and 32 from
SLUM 2 were interviewed.

)

Table 2: Characteristics of women in the sample
Number
Indicator

N
Current age

More than half the
interviewed women were in
the age group 25-30 years.
About two thirds had got
married before the legal
age of marriage i.e. 18
years and less than half
were illiterate.

Age at marriage
Education

Living children

<-20
21-24
25-30
31-34
35+
<18
>-18
Illiterate
Literate
0___

Twenty-three women
1
(more than one third)
_2__
reported 3 or more living
3+
children and six reported
Abortions
1__
no living child. In all, i.e.
2
in their entire reproductive
3+
career till date, these
women reported a total of 92 induced and 5 spontaneous abortions.

62
6__
10
35
8__
_3__
40
22
28
34
6__
8__
25
23
42
13
8

4

Foundation for Research in Health Systems, .4 hmedabad
8"' May 2003

While this was the overall picture, women selected in SLUM 2 had some special characteristics or ’
differences from the women selected in SLUM 1. Women in the sample from SLUM 2 were
comparatively younger, majority i.e. 8 out of 10 got married before 18 years of age, more than two
thirds were illiterate and one in five women reported having no living children. There was not a
single woman in SLUM 1 without a living child and more abortions were reported by selected
women from this slum.
Induced Abortions
Though women in the
sample reported 92
abortions, the service use
related information
presented hereafter refers
to 62, i.e. the latest
abortion per woman in the
five-year reference period
before the study.

Table 3: Induced abortions
Indicator

Reasons

Decision
by

Family planning
Health problems
Sex determ inatn
Doctor________
Family members
Couple________
Wife__________
Husband

SLUM 1
19
3
8___
2
10
10
4___
4

Area
SLUM 2

15
15
2
15
5
4___
8___
0

Total
34
18
10
17
15
14
12
4

More than half of the total
abortions (34) in last five
years were reportedly for
limiting family size or spacing children. Ten were after sex determination and eighteen on health
grounds usually consequent to medical advice.
A little more than a fourth of the women reported that as they had their pregnancies terminated on
medical advice, the decision was that of the doctor. An equal proportion of abortions were (15-14)
reportedly either decisions of the family or the couple. Twelve abortions were a result of decision of
the woman alone and four of the husband.

While women in the sample from SLUM 1 (8) reported more abortions after sex determination, those
consequent to medical advice were more common in SLUM 2 (15). More women from SLUM 2
reported the decision to be their own or that of the doctor as more abortions were reported to be on
medical advice.
(

Service facility used

Majority (48) of the
abortions took place in
private hospitals or non­
government run hospital
(12), only a small number (2)
were conducted in the
government or municipal
tertiary care hospitals.
Qualified gynaecologists
conducted all the abortions.

The major determinants of
choosing the providers were

Table 4: Service facility used
Indicator
Provider

Reason for
preference

Private hospitals
Government
hospitals______
NGQs
Reputation
Vicinity_______
Familiarity____
Cost__________
Confidentiality

SLUM 1
16
2

Area
SLUM 2
32
0

Total
48
2

12
Yes
No
No
Yes
Yes

0
Yes
Yes
Yes
Yes
No

12
Yes
N/Y
N/Y
Yes
y/n

Foundationfor Research in Health Systems, Ahmedabad
8,h May 2003
their reputation, vicinity, familiarity and cost of services. Women thought twice about using the
government tertiary care hospitals. According to them a lot of time is wasted in waiting and going
through formalities

5

Close by location and familiarity with the provider were the main reasons for preference for a
particular provider in SLUM 2. In SLUM 1 women who reported multiple abortions and/or resorted
to abortion after sex determination tests reported change of clinics for secrecy, and thus
confidentiality was a major deciding factor for preference.

Services received

Table 4: Service received
More than one third of
Indicator
Area
the women (25) reported
SLUM 2 Total
SLUM
1
ignorance about the
Method
25
16
Do
not
know
9
method used for their
used
16
By machine
8
8
abortion. Women
4
Curetting
2
2___
reported that the doctor
Two stage
16
10
6
told neither them nor
their family member
about what exactly would be done. But they added that they were not interested in knowing about it
either. Twenty of the women interviewed reported that the pregnancy was terminated with a
machine (suction method) or by curetting. Sixteen reported two-stage method first using tablets and
then through a procedure they called as 'delivery’. One reported removal of the product of
conception by hand.
More women in SLUM 1 underwent two-stage abortion, while more women in SLUM 2 were
ignorant about the method used. This perhaps could be because of higher prevalence of abortion after
sex determination in SLUM 1 and lower level of literacy in women from SLUM 2.

Women did not report any preliminary tests, other than those who had sonography for foetal sex
determination before the procedure. Many of them went to the doctor after confirming their
pregnancy through a urine test done at private pathology laboratory but barring 2-3 none mentioned
vaginal examination for confirmation of pregnancy.

They reported that most doctors took their consent but also insisted on presence and consent of an
accompanying person. All women reported receiving post-operative advice from the doctors, but it
was only in terms of taking prescribed painkillers and rest. Majority women paid between 400 to 600
rupees for abortion. High cost of abortion did not seem to be a deterrent towards undergoing abortion
in private facility. Some how or the other women managed to resource the amount needed and in
SLUM 2 more 40 than percent paid for the expenses from their own personal savings. In SLUM 1,
especially in the joint families, where the family had consented for the abortion, the expenses were
borne by the in-laws. Most women reported being satisfied with the services they received.

Characteristics of service facility/providers in the sample
In all 18 providers were interviewed. Six private gynaecologists, a Medical Officer each from the
national and local level NGO, two gynaecologists from the government / municipal tertiary care
hospitals, five qualified general practitioners, one nurse and two dais.

The tertiary care hospitals provide the entire range of preventive, curative and specialists services.
The clinics run by the two non-government organisations and private gynaecologists provide curative
and preventive obstetric and gynaecological services. While the general practitioners provide

6

Foundationfor Research in Health Systems, Ahmedabad
8"' May 2003

curative and preventive services for all age groups and sexes, the Nurses and dais conduct only
antenatal checkups and deliveries at home.

The tertiary care hospitals and the national level NGO are the recognised centres for conducting
induced abortions. The recognition status of the local NGO could not be ascertained and three out of
the six private gynaecologists claimed that they had applied for recognition but the process was
delayed because of reasons not known to them, and despite their repeated efforts to follow up. The
remaining three refused to discuss their recognition status.
Though, no special training is required of qualified gynaecologists for conducting the procedures, it
was found that none of the other providers had any special exposure or training for conducting the
abortions. The general practitioners, nurses and dais in any case only referred women to the
gynaecologists, so their lack of exposure to training was not an issue.

Table 5: Characteristics of service facility / providers in the sample
Government Municipal National
Local
Private
Tertiary
Tertiary
NGO
NGO
Gynaec.
Services
ALL
OB/GY
ALL
OB/GY
OB/GY
Provided
Curative
Curative
Curative
Curative
Curative
Preventive
Preventive Preventive Preventive Preventive
Specialist
Specialist
Recognised Yes
Yes
Yes
??
Not all
for MTP
Special
No
No
No
No
No
training
MTP
75-100/
75-100/
100-200/
150-200/
20-30/
Case load
Month
Month
Month
Month
Month

General
Practitn
ALL
Curative
Preventive

Nurses
Dais
ANC
Delivery

No

No

No

No

20-40/
Month

1-2/
Month

The case load of women seeking termination of pregnancies was highest in the two NGO run clinics,
with the local NGO reporting 150 to 200 cases per month, many of them from outstation. While the
local NGO reported the highest case load per month, the doctor handling the cases at the time of the
study was a postgraduate student of the local medical college and therefore not even a qualified
gynaecologist.

Characteristics of cases at the service facility/providers in the sample
According to the providers, women from all age groups sought abortions, with more than 60% of
them approaching them within the first trimester. There was variation in the case profile of the
service facilities. The provider at municipal tertiary care hospital was categorical that they did not
conduct induced abortion in unmarried women. All the others said that they must have done so as
there was no way of finding out whether the woman was married or not, if she came with a male
partner. On the other had, the nurses and dais said that their clientele was only unmarried young
girls, whom they then referred to NGO run clinics or private gynaecologists who did not ask too
many questions.

Younger age group of abortion seekers seemed to prefer the NGO run clinics or the nurses and dais.
The other service facilities gave services to all age groups. The women going to tertiary care
hospitals were poor and illiterate. Those going to private gynaecologists were obviously from better
socio-economic strata. The municipal tertiary care hospital, and the two NGO run clinics claimed
that a large proportion of their clientele was from the minority community.

f

7

Foundation for Research in Health Systems, A hmedabad
8"' May 2003

Table 6: Characteristics of service facility / providers in the sample
Private
Local
Governme Municipal National
Gynaec.
NGO
Tertiary
NGO
nt
Tertiary
Un/Marrie Un/Married Un/Married
Profile of Un/Married Married
15-45
d
25-30
20-45
MTP
15-45
(Il)literate
Illiterate
(11)1 iterate
Illiterate
25-30
seekers
Poor/Not
Poor
Poor
Poor
(11)1 iterate
Poor
Minority
Minority
>75% 1st
Poor
Tri
80% 1st
>80% 1st
>90% 1st
Minority
Tri_____
90% 1st Tri Tri_______ Tri_______
Reasons
Pre/extraSpacing
Pre/extraPre/extraPre/extramarital
Limiting
marital
marital
marital
Medical
Spacing
Limiting
Spacing
Spacing
Limiting
Medical
Limiting
Limiting
Female
Female
Female
fetus
fetus
fetus
Medical
Medical

General
Practitn

Nurses
Dais

Un/Married
15-45
(H)literate
Poor
>80% 1st Tri

Unmarrie
<21
(Illiterate
60% lstT

Pre/extramarital
Spacing
Limiting
Female fetus

Pre/extramarital
Female
fetus

The reasons for abortion ranged from pregnancy out of wedlock, for family planning reasons,
medical problems and after sex determination. Except the municipal tertiary care hospital, and the
national NGO run clinic, all the others reported that they may have conducted abortions of women
who had undergone foetal sex determination. In their view it was not possible for them to confirm
whether a woman had undergone the test. The two facilities who claimed that they did not said that
they went by the obstetric history of the woman and a woman who had two daughters or had come
after 8 weeks was assumed to have come after sex determination and was therefore refused the
service.

Interestingly, all providers interviewed stated that about 30 percent of the women in their experience
underwent 2-3 induced abortions per year and went to different providers the next time.

Course of service use according to the service providers in the sample
There appeared to be a common thread in the process / course followed by the abortion seekers as
described by the providers. The process, according to them, differs for married and unmarried
women.
According to them the married woman usually cite reasons such as unwanted pregnancy soon after
marriage, after previous childbirth, female foetus, household responsibilities, poor financial
condition of the household, and not being established in the chosen career. Interestingly women
whose husbands are abroad also cite terminating the pregnancy to avoid rejection of Visa to the
country their husbands resided in! Married women come with the approval of their husbands and
usually within a fortnight of missing their periods except those who come for termination of female
foetus. They come a little later after 8 weeks as they undergo either Chorionic villi aspiration,
amniocentesis or sonography. Women try 'hot’ food such as jaggery, radish seeds, or take Primolute
or Epiforte from the local pharmacies, as soon as they miss their periods. When they do not get
withdrawal bleeding, they go for urine test either using a kit from the pharmacy or at the local
pathology laboratory. A very small number is aware of the locally available RU 486 preparation
called MTPill and tries that. The rest then either directly consult a gynaecologist or their family
doctor who refers them to a gynaecologist for abortion. The husbands of these women are typically
aware but the other family members may or may not be aware of their decision. These women get

Foundation for Research in Health Systems, Ahmedabad
8"' May 2003

8

admitted to the clinic which offers the services and are discharged within a few hours (2-3) after the
procedure, at their convenience.
Unmarried women usually come with either their partner or mother and at a later gestational stage
than the married ones. The reasons for termination other than the illegitimate pregnancy are career
and ongoing Visa process. The earliest they come is generally 8 weeks after missing the periods.
They too try 'hot’ food such as jaggery, radish seeds, or take Primolute or Epiforte from the local
pharmacies. When they do not get withdrawal bleeding, they consult either a local nurse or dai, or
their family doctor. All of whom refer them to a gynaecologist for abortion. The family other than
the mother and partner are kept in the dark about the pregnancy and decision for abortion. These
women are subjected to a lot of'inquisition’ at the hospitals. The government providers say that
though they do not refuse the services they can intuitively figure out which women are unmarried.
To dissuade her from repeating the experience and also to safeguard their own self, they ask
questions. The private providers give the services without asking too many questions. The women
are admitted to the clinic which offers the services and are discharged within a few hours (2-3) after
the procedure. Those who come late sometimes need a two stage procedure for termination and
sometimes require a longer stay.

Service provided according to the service providers in the sample
The providers mentioned that they do not conduct a thorough physical examination. The private
providers complained that women refuse internal examination and therefore many times the
providers do not do it. No routine tests are done though all the providers feel that these (blood group
and haemoglobin) are necessary for safety purposes. They believe that elaborate tests and
examination would deter women from accessing safe, qualified providers. History of amenorrhoea ,
positive urine test and sonography report confirming pregnancy are the only pre-requisites for
conducting abortion. For women coming in the 12-13 weeks period they ask her to wait till after 14
weeks as this gestational age is too late for one-stage methods and too early for the two stage
methods.

Once the woman comes with this history or test reports, the providers admit her, take her consent and
also that of the accompanying person to safeguard their own practice. This is particularly when they
anticipate either health problems or problems by the family of the woman.
They use vacuum aspiration method under local or general anaesthesia upto 12 weeks of gestation
and two stage methods for pregnancies with higher gestation. Most of them, however, prefer
dilatation and currettage and are critical of and do not use electric vacuum aspirator because of
erratic power supply and difficulty in procuring the equipment. They are also not in favour of RU486
because of its uncertain outcome and possibility of incomplete abortion requiring surgical
intervention.

The woman’s hospital stay depends on the gestational period and increases with increase in the
gestational period. Before she is discharged the woman is given Tetanus toxoid injection, antibiotics,
anti-inflammatory, painkillers, and rarely Mala D. The women are called for follow-up only in case
of complications. The providers insist that they counsel the women about the consequences of
aborting first pregnancy and of aborting repeatedly. However, they claim that they rarely come
across complications like incomplete abortion, infection and perforation. Not a single one of them
has come across infertility or death because of abortion.
The charges for abortions, as disclosed by the providers, are lowest at tertiary care hospitals and
highest at the private gynaecologists’ clinics. The local NGO advertises abortion services for Rs. 150
but charges anywhere between Rs. 350 to 2000, depending on the gestation, woman’s marital status,

Foundation for Research in Health Systems, Ahniedabad
8"’ May 2003

termination on account of sex determination and also on the procedure and medicines used. All the
providers were of the opinion that cost of abortions cannot be standardized and should be left to the
provider.
Perceptions of service providers in the sample - about the services

The providers feel that women are by and large satisfied with their services. The ones who undergo
repeat abortions, are hardened, have no sense of remorse about their actions and most go to a new
place the next time.
Interestingly, even the private gynaecologists claimed that they do not like to terminate pregnancies
but do so because of the demand. According to them, if they do not do it, the woman may go to
someone who is not qualified to do it. Their discomfort with termination is not only because of their
conscience but also the hassles involved in giving the service as they have to sometimes face the ire
of women’s family and the society. Providers from tertiary care hospitals and some private
gynaecologists were explicit in their disapproval of the procedures and said that they insisted on
women adopting some family planning method. At the same time, contradicting this opinion they
also say that since the abortions are used to limit and space children, they should be included in the
government family planning programme.

Perceptions of service providers in the sample - about the MTP Act
Providers view MTP Act stipulations as too stringent and to some extent redundant. For example
training of private providers is deemed impractical, the registration process tedious and the
administrative delays in getting recognition, troublesome. They also feel that the Act provisions are
open to interpretation and feel that though liberal in its present form, it should be made more so in
view of the fact that it is difficult to validate reason for termination and to refuse service based only
on suspicion or assumption. The records for cases other than those for termination after sex
determination, to them, are a waste of time, serving no particular purpose and should be done away
with. To them two doctors opinion for later terminations appear un-necessary in tertiary care
hospitals and unrealistic in private clinic. They have strong reservations about the prevalent view of
some researchers and policy makers of using paramedics for service delivery as they feel that the
accountability in such cases would be that of the person who would be handling the complications
resulting from such services and not of the person who gives the service. Instead they propose
categorization of cases as low and high risk with paramedics being allowed to give services only to
low risk cases. Overall, in their view that Act needs a relook as the methods have changed, the need
has increased and the legal issues are at the forefront.

d. Discussion

The data showed that awareness in women was high about availability of abortion services but not
about the technical provisions of the Act. The predominant use of abortion was for spacing or
limiting the family. They were not aware that abortions were not legally allowed for this purpose.
They were aware that termination of pregnancy after sex determination was illegal but that did not
deter worhen, particularly from SLUM 1 going for abortions of female foetus. This could perhaps be
because of the prevalence of the custom of dowry in the communities inhabiting the slum. On the
other hand in SLUM 1, abortions were for pregnancies as a result of the custom of child marriage
with 'gauna’ at a much later stage, which did not prevent the couple from cohabiting in the
intervening period. This was substantiated further by the data which showed the women in SLUM 2
to be comparatively younger, with no / lower education and one in five with no children. Having
said that, it also needs to be mentioned that more women in SLUM2 reported that their abortions
were consequent to medical advice for which we have no explanation.

9

Foundationfor Research in Health Systems, Ahmedabad
8"' May 2003

10

Women who reported that their pregnancies were terminated on medical advice, said that the
decision was that of the doctor. Family members other than the husband were not necessarily
involved in abortions to regulate family size but abortion after sex determination was a family
decision. Accessing qualified provider did not appear to be the first step, over the counter medicines
were tried before qualified gynaecologists were approached. Majority of the abortions took place in
private hospitals or non-government run clinics. The major determinants of choosing the providers
were their reputation, vicinity, and familiarity.
Women accessed gynaecologists who admitted them, conducted the abortion and discharged them on
the same day. Insistence on consent of the accompanying person was seen as a precaution by the
provider and not as a violation of women’s empowerment and the women themselves did not seem to
mind this. The pre-abortion investigations and examinations were perfunctory and post-abortion
follow-ups in absence of complications were non-existent. The providers argued that women refuse
examinations and routine tests and insistence on these would affect their access to safe, qualified
pioviders. Counselling was not seen as a critical element of service either by the women or the
providers. Cost, though a critical determinant of selection of provider was not a constraint in seeking
the service once the decision to terminate was taken. Overall, women were by and large satisfied
with the services.
The process seemed to be to a large extent demand driven with the women dictating some of the
terms such as hospital stay and post-abortion care, flouting the medical norms or requirements. These
were also some of the reasons why private services were preferred and flexibility of private providers
to meet the demands of women and their families in complete contravention of the MTP Act
appeared to play a sizeable role. The providers of the services to the largest number, were not
technically recognised for service delivery but that did not prevent them from giving the services.
The providers, mainly private gynaecologists, conversely, had their own constraints. There were
undue delays in certification process in their view due to unrealistic requirements under the Act and
impractical stipulations for provision of services. The veracity of reason for abortion was difficult to
substantiate and to refuse services was unacceptable to them as they feared that it would drive these
women to the unqualified providers.

To conclude, in view of the changing social scenario where abortions are used for terminating
pregnancies for reasons other than those mentioned in the Act, and over the counter medical abortion
pills are available, the Act needs a relook. The training requirements under the Act which are
impractically stringent for qualified providers needs to be amended particularly when there is
proposal to provide the services through trained paramedics. At the same time the professional
bodies of gynaecologists need to come up with measures to handle the laxity of providers in abiding
by the Act and medical code of ethics. Thus, policy makers and the service providers have to work
jointly to make the Act more realistic and implementable.

vo K - ■? -

Executive Summary- Indranee Dutta

This study is sponsored by the Centre for Enquiry into Health and Allied Themes (CEHAT),
Mumbai, and is a part of the larger project called 'Abortion Assessment Project India
(AAPI)', being carried out in six states of the country. This multicentric study is one of the

five components designed for making a comprehensive assessment of abortion as a public
health issue. The chief purpose of the study is to make an objective assessment of the

abortion situation in the country.

The analysis basically deal with issues, such as, the

abortion incidence, fulfillment or non fulfillment of the safety questions, quality of the
health care facilities providing the abortion services, quality of the service delivery, quality

of the providers and so on.

I he state of Mizoram has been selected by the project formulators along with five other
states of the country, on the basis of eight health indicators of women, viz., sex ratio,

percentage of institutional delivery, maternal mortality ratio, neo natal mortality rate, female

infant mortality rate, couple protection rate and female literacy rate. Considering all these
indicators Mizoram is placed in category' one.

Standardised and common methodology has been followed in the study. The survey method
using structured protocols along with observation checklists, as designed by the central
body, have been used. Since Mizoram is a small state, all the districts have been covered in
the study.

The salientfindings ofthe study are as folloyvs:

Health care in Mizoram is predominantly a public domain, with only three private facilities
in the state. All the public health care facilities in Mizoram above sub centre level are

premitted to deliver abortion services provided a trained medical practitioner is posted.

Registration and certification are not required as such.

x

9

I

I

Mizoram appear to be well provided in terms of facility infrastructure, although PHCs lack
beds in recovery room for the women undergoing MTPs. However, equipment availability
position is not very sound, as only around 10 percent of the facilities have complete sets of
MV A or EVA and only 79 percent have complete set for D&C. Ultrasound facility is

available only in Aizawl Civil Hospital. Sonography is not used for abortion purpose.
While equipment like oxygen cylinder, autoclave drum, steam sterilizers are present in most

of the health facilities, provision for sterilization related consumables are inadequate.
Similarly, except for contraceptives, other drugs related to abortion are not widely available.

Concentration of doctors with higher qualification is observed in Aizawl district. Lack of

anaesthetist is conspicuous, especially in Lunglei and Chhimtuipui. All the MDBS doctors
are MTP trained.

On an average 75 abortions are conducted per month in Mizoram. In most of the facilities

reasons for postponing services did not occur in last three months prior to the survey.

Despite that all the facilities remain open at night, only in 37.5 percent of the facilities
doctors are actually available for the women seeking services at night.

While majority of the facilities could deal with excessive bleeding in house, very' few could

deal with the other complications. Post abortion complication is quite high in Mizoram,
around 7 percent of all abortions that took place in Mizoram during 3 months prior to the

survey had post abortion complications.

Only 25 percent of the facilities provide all the services considered part of the RH

The only guidelines for conduct of MTP, which is available with only 29 percent of the facilities, is
the MTP Act.
Maximum numbers of abortions, as reported by the providers have been conducted up to 8
weeks of gestation. D&C is the most predominant method both in 1st and 2nd trimester

aboritons.

x

io

It is surprising that more

before discharging a woman

1 he study icvealed that all the doctors do routinely provide both pre and post abortion

counseling. Around 14 percent providers do not routinely discuss contraception with the

women seeking abortion.

So far as aseptic condition is concerned although the metallic instruments are sterilized as
per standards, rubber gloves and cannulae are not sterilized following the standard methods

for the same. Again only 31 percent of the facilities adhered to the universal precautions
necessary for processing instruments for re use.

All the facilities in Mizoram are found to be located at a distance of less than 1 k.m. from

the road accessible by public transport and in majority of the cases (79.3 percent) the

approach road to the facility is metalled.

It was revealed that a quarter of the facilities would offer MTP services if a woman comes
alone for terminating her pregnancy.

As per the quality of care index (QC1), in Mizoram the majority of the facilities fall in the

score range of 31-36, meaning the quality of care is around half-maximum attainable
standard.

X

11

VA'~ 'S’

PROCESSES AND FACTORS UNDERLYING CHOICE OF INDUCED ABORTIONS:
A QUALITATIVE INVESTIGATION IN RURAL TAMIL NADU
Rural Women's Social Education Centre,
Chengalpattu. Tamilnadu

P. Balasubramanian, T.K. Sundari Ravindran and U.S. Mishra
Abortion was legalised in India by the Medical Termination of Pregnancy (MTP) Act of 1971. Over
the decades since the legalisation of abortion, a number of studies have been published on the
incidence of abortions within and outside approved medical facilities, on the nature, distribution and
quality of abortion services, characteristics of women seeking abortion services from approved and
unapproved sources, and on abortion-related morbidity.

A systematic review of abortion studies in India shows that most abortion seekers were in the 20-34
years age group, married and had not used a method of contraception prior to the pregnancy that was
sought to be terminated.
In all these studies, women were using abortion to space births or prevent an additional birth. Many of
those who did not want more children underwent sterilisation along with the abortion. However, those
who had terminated a mistimed pregnancy rarely accepted a reversible method of contraception after
the abortion.

Why do women undergo induced abortions rather than use contraceptives effectively to space and
limit births? Could induced abortions, rather than being an indicator of women’s exercise of their
reproductive rights, signify their lack of reproductive and sexual rights?
We know relatively very little about the reasons why and the processes leading to women's choice of
induced abortion to space births. We also do not know whether changes in indicators of women's
status, the wider social acceptance and high levels of use of birth control measures over the past
decades has made any difference to the extent of reliance on abortion for birth spacing. Such
information is vital for the planning of interventions to prevent unwanted pregnancies, which would
have significant positive impact on women's health. So to meet the objectives the study was
conducted.

The research questions were:
1. What role does gender power relations within married relationships influence the choice of
induced abortion to space births? and

2. How has this role changed during the course of a generation of major changes in the social,
economic and demographic context?
3. Are there differences in gender power relations also between couples who are ‘ever users ’ of
induced abortion, and those who are ‘never users ’ of induced abortion?

1

Present Study
The present study was carried out by Rural Women’s Social Education Centre (RUWSEC). RUWSEC
is a grassroots women’s organisation based in Kancheepuram district of Tamilndau, working on
women’s reproductive health and rights issues for more than two decades.
The ultimate goal of the study is to design community based interventions to prevent unwanted
pregnancy, based on the in-depth understanding of the processes leading to the married women’s
choice of abortions to space birth. The study was funded by Health Watch Trust New Delhi, India. The
study was carried out during 2002.

Study area
Tamil Nadu is among the states of India, which have witnessed a rapid decline in fertility since the
early eighties. Tamil Nadu has achieved near- replacement fertility at high rates of infant and child
mortality. According to estimates based on NFHS-I data Tamil Nadu had the highest rates of abortions
among Indian states. The widespread use of abortion as a method of birth spacing was also evident in a
study on fertility transition in Tamil Nadu carried out by two of the authors.

The study covered 98 hamlets in Thiruporur and Thirukazhukundrum blocks of Kanchipuram district,
Tamil Nadu, which constitute the project area served by RUWSEC.
RUWSEC's project area covered 6861 households and a population of 30,125 persons in 1996-97,
according to the organisation's database. The sex ratio was 985 females per 1000 males and the
average household size was 4.40 persons. The population covered belongs to a low-income and
socially marginalized group. There were in 1996-97, 4117 currently married women who had not yet
reached menopause. The average number of pregnancies per woman was 2.9, and the average number
of live births per woman was 2.5.There was a high rate of pregnancy wastage: Forty-two of 1000
pregnancies were either miscarried, aborted or stillbirths.

Fifty two per cent of the 4117 women (2119) have adopted a method of contraception. However, use
of modern spacing methods was still very low - less than 3 per cent (1.3 % on oral pills, 1.3 % using
an IUD, and 0.2 % using condoms).
Methodology
This was a qualitative study, consisting of in-depth interviews.

The sample was drawn from two groups of women, and their husbands:
a) . Older women: Ever married women who have completed childbearing (are either
menopausal or have undergone sterilisation) and have adult children (above 18 years).
b) . Younger women: Ever married women below 30 years who have not undergone
sterilisation as yet
Within each group, we selected equal numbers of 'ever users' of abortion and 'never users of abortion’.

Never users of abortion were selected from RUWSEC database to represent diversity in terms of social
economic and demographic characteristics within the fairly homogeneous community that RUWSEC
is working with.

2

Ever users of abortion were identified through women who had voluntarily reported having undergone
an induced abortion during our routine data collection and also through snowball technique. Women
participants were interviewed first and then Husbands of women selected for the study were
interviewed with the consent of the women.

Eight different interview guidelines were used, one for each group of study participants: ever and
never users of induced abortion, men and women, in two age categories.
The ethical norms were strictly followed during the field data collection transcribing and data storing
process. Five-member ethics committee was set up to monitor and review the norms followed in the
study.
Findings from the study

A. Socio-demographic characteristics of study participants

There were 110 respondents in all, 66 women and 44 men. This included 44 couples and 22 women
who did not want their husbands to be interviewed. All 44 men were husbands of women interviewed.
Of the 66 women, 34 had had one or more induced abortions in their life time (‘ever users’) and 32
had never had an abortion (‘never users’). Twenty-three of the 44 couples were ‘ever users’ and 21
were ‘never users’.
Fifty-eight (57) respondents - 24 men and 33 women - belonged to the ‘younger’ category in the
sample we had selected. Fifty-two (53) participants, 33 women and 20 men, belonged to the ‘older’
category.

The majority of study participants were Hindus and belonging to the ‘dalit’ community. Forty five per
cent (50 out of 110) participants came from households that possessed some land The average
household size was 5.24, and was 4.82 and 5.65 respectively for the younger and older group of
respondents.
The mean age of women respondents was 26.76 years and 40 years respectively for the younger and
older groups. For men, the mean age was 31.5 years and 48.3 years respectively.
There was a wide sex difference in the proportion of persons with schooling. Only about 60 per cent of
younger women and 47 per cent of older women in the study had schooling. Among men 80.3 per cent
of the younger and 60 per cent of the older groups had attended school.

The majority of women and men in the study were agricultural wageworkers. The average age at
marriage was 17.79 and 16.53 for younger and older women respectively, and 22.46 and 21.7 for men.
The women included in the study had an average of 4.18 pregnancies each (3.21 and 5.21 number of
pregnancies for young and old age group respectively). The young age group women had 2.15 and
older women had 4.44 children ever bom.
In the rural setting in which this study is based,-thc-vast majority of the marriages are arranged by
families. However, the consent of the bridegroom and bride-to-be is usually asked. Fifteen of the 44
couples were related to each other before marriage. Of the 35 arranged marriages, 8 women and 2 men
reported being forced into the marriage.
Dissatisfaction with the state of their marriage was expressed by 10 wives (but not their husbands) one

husband (but not his wife), and one couple. All those who had reported a forced marriage were
unhappy with the marriage even after several years.

3

B. Household decision making

Overall, men dominated in household decision-making, and were responsible for all-important
decisions. Some husbands consulted their wives when taking major decisions, but in no case could a
wife take independent decisions except in trivial matters.

Sixteen of 44 couples said that all-important decisions were taken by the husbands, and decisions on
some day-to-day matters were taken by the wife. Ten of the 16 were younger couples.
‘lean buy things for myself like flowers, clothes and groceries. Only during festivals and such
major occasions does he buy household items. '(YWEU-8)
'In my household I take decisions about money matters and important matters like purchase of
dress and jewels during festivals etc. She can decide on her own to buy things of daily needs
for households, and about children health.'(YMEU-7)
In 11 of 44 couples, both the husband and the wife said that the man took all the decisions, and the
women had no say in running the household. Five of these were younger couples, and six were older.

I take decisions in my family. I will not allow her to take any decisions. She
cannot have
any money of her own, if she has I take it away. I have beaten her for her wrong decisions. So,
she never takes any decisions.’ (YMNU-7)
He takes all decisions. I didn’t even purchase a saree for myself during my 5 years of married
life. One day when I took my son to hospital without his permission, because he was not there,
he abused me. “You, an eloped donkey, how dare you (“Odi vantha kaluthaikku enna
thariyam
I have to call him to accompany me even for small things like to going to the
bathroom at night. Otherwise he calls me a prostitute. (YWNU-4)

In 9 couples (4 younger and 5 older), the men and women viewed their decision-making roles
differently. While the men said that they always consulted their wives and that decision-making was
joint, the women felt that they did not have an equal role in decision-making.

For example, according to the husband,
In my household we both take decisions jointly with due consultation. She can buy flower,
dress and other things for herself. Regarding borrowing or lending money we both take
decisions jointly. ... We both jointly make decisions about children’s health andfuture. (YMEU
However, his wife says that,
‘Usually he takes decisions in my family. He never considers my view in the decision making
process. I have to accept his decisions even to buy things for myself like flower, clothes. He
never bothers about children’s future and education. For example yesterday, I borrowed some
money from my mother and bought notes/books for children .He never thinks about it. (YWEU
~5)

Only five couples out of the 44 (3 younger, 2 older) interviewed agreed that they made joint decisions.

c. Sexual relations within marriage

Talking about sex and expressing desire:

4

Even though sex is a common desire for men and women, the vast majority of women (58 out of 66)
stated that they did not talk about sex with their husbands, or express their sexual desire in other ways.
Contrary to women’s statement, 31 out of 44 men in the study said that they spoke about sexual
matters with their partners openly.

The women often gave a stereotypical response, ‘How can women talk about sex? ’
Most women said that they had sex whenever their husbands wanted. Some said that they felt shy even
to look at his face the morning after a night of sex. This was true even for women who had had ‘love’
marriages, and those who had become pregnant before marriage.

I didn’t know about sex before marriage and I have never spoken about sex with him. Even
after marriage we hadn 1 joined’ (had sex) for six months because of I was fearful and shy.
(OWEU-2)
We were lovers and had sex before marriage. As a result of that I conceived before marriage. I
don’t talk about sex with him; this is something secret and happening in night times. So, how
could we talk these things openly? (YWEU- 12)
Non - Consensual sex

Non-consensual sex was widely prevalent. In nearly half the couples (21/44), the women (17) or both
the partners (4) stated that the woman could not refuse if her husband desired to have sex. Five men
also talked about their inability to take no for an answer when it came to sexual matters. Many of the
women whose husbands were not included in the interview (16/22.) had experienced non-consensual
sex. Overall, 37 women reported experiencing non-consensual sex, ranging from being nagged into
submission to outright sexual violence.

One commonly heard comment from most women was that if they refused, the men abused them
verbally and asked ‘If not me, who do you want to sleep with? ’ This appeared to be a routine threat to
cow women down into submission.
In its mildest form, non-consensual sex led to the woman feeling humiliated and resigned to her fate.
Several women reported that ‘they lay like an inanimate object -like a piece of wood, and he went
ahead. ’

Women were also forced into having sex against their will under threat of their husband seeking
sexual pleasure elsewhere. Nine men (of 44 couples) had one or more sexual partners besides their
wives.
Sex is a regular event for him; he has it daily before he goes to sleep. Whenever I say no to
sex, he beats me and says, “ I will go in search ofanother woman. ”(YMNU-5)

He has extra marital relations and I once rejected his desire because of fear of getting
infections. That time he beat me badly. He had sex by force and said, even though I have sex
with a thousand women, I get something different from you. (OWEU — 14)
Of the 21 couple in whom non-consensual sex was reported, 19 were reports of regular or routine
sexual violence. Fourteen couples reported other forms of intimate partner violence, bringing the total
number of couples reporting sexual or other forms of violence to 33 of 44. Of the 66 women
interviewed, exactly half - 33 women- reported experiencing violence: 23 reported sexual violence
and 10 reported other forms of intimate partner violence.

5

Further, from an analysis of non-sexual violence reported by couples, it appears that women underreported violence that was not sexual unless it was extreme. For example, in 9 of 14 couples reporting
non-sexual violence, it was the husband who reported that he often beat his wife when he was drunk or
because ‘she answered back’, whereas the wife did not report experiencing violence from her husband.
The kinds of non-sexual violence that women did report were quarrels related to the husband’s extra­
marital affairs, and routine drunken beating and extreme forms of cruelty.

He beat me with his shoes. I had delivered only two weeks ago, he was angry that I had
delivered a third girl child (YMNU-13).

Communication and relationship between a couple could hardly be on equal and easy terms within
such a context of violence. This plays out in the extent to which women are able to have a say in
matters related to the regulation of their fertility.

Sexual rights
Despite the reality in which they live, there were few women who believed that men had a right over
women’s sexuality. They regretted that for many women, it was not possible to exercise their sexual
rights.

Women should have the rights where and when to have sex. I am a slave. How can I exercise
my rights? (YWNU- 5)
I have the right to decide whether, when and where to have sex. But generally men view women
as childbearing machines (OWNU-IO)
Contraception: Knowledge and Practice

Reversible methods of contraception were still not very familiar to study participants. Only 29 of 66
women (44%) knew about permanent as well as reversible methods of contraception in some detail. A
slightly higher proportion of men (25 of 44 or 58%) than women knew about reversible as well as
permanent methods of contraception.
There were several interviews where after listing a whole range of contraceptives, the respondent
would say later in the interview that they did not use any reversible method because he/she ‘did not
know about any method. ’ What this may indicate is that their knowledge about these methods is based
on hearsay, which is different from their knowledge of the sterilization operations, which they know
from the lived experience of women for more than a generation now.
In the younger age group, only two of 33 women were currently using the ‘safe period’ method. In the
older age group, 17 of 33 women or a little over half the women had undergone sterilization.

When examining ‘ever’ use of contraception, however, a different picture emerges. Overall, only 10 of
66 women have never used a method of contraception. Twenty-nine women (44%) had used a modern
reversible method at some time in their reproductive lives, and 10 had used periodic abstinence for
spacing.

Among the older couples, not knowing much about any method except the sterilization operations is
an important reason for non-use of any spacing method.Among younger couples Fear of side-effects
and embarrassment about using contraceptive methods in a context of lack of privacy were the most
commonly stated reasons for not using reversible methods of contraception such as condoms, pills and
Copper -T. Copper-T was especially distrusted, and women and men had heard that it could cause
serious problems.

6

JVe had decided to use copper-T. But, some have told me that copper-T lead to weight gain. She is
already fat so, we dropped the idea. (YMEU- 9

My cousin’s wife had Copper-T inserted after her delivery, but she did not know. After some months
she had severe lower abdominal pain, and excessive white discharge. When she went to a doctor, they
found the Copper-T and removed it. Now she is all right. (YWEU-3)

Many prefeired to have all the children and have the operation, because reversible methods were only
appropriate for urban and upper class women who did not have to perform hard manual labour:

‘Temporary contraceptives are not suitable for us. Because, we do hard manual work, we have
to woi k in the field all round the year, there is no rest. So these methods lead to various
problems. I think after getting 2 or 3 children it is better to go for sterilisation. (YWEU-3)

There was also a belief that if a woman has long birth interval between two pregnancies, the same
interval would continue for later pregnancies, and that no specific method needed to be used:

7 know that I will not conceive soon. That is why I haven’t used any method. Those who get
pregnantfrequently need to use these modern (meaning reversible) methods. (YWNU-8)
As for condom use by men, many non-users stated that they did not want to use it because it would
interfere with sexual satisfaction. There were also situations where men felt embarrassed to use it
because of lack of privacy, and other situations where men wanted to use the condom but their wives
were opposed to it.

1 will use Nirodh (condom) but I am worried that if some one comes to know about it, they will
mistake me (thinking I have sex with other women). This is a matter of my prestige. (YMEU ^)

'Some years back, my husband got some condoms
condoms from
RUWSEC camp.
with him
from RUWSEC
camp. II fought
fought with
him
saying ‘did you bring it so that you can have relations with other women'? (OWEU-16)
Irregular use of reversible methods
A significant number of couples, especially in the younger age group, have used at least one reversible
method of contraception some time in the past, although very small numbers of them were current
users. The numerous barriers to effective use of reversible methods included side effects, lack of
privacy, irregular availability of free supplies and the cost of supplies to be bought from the
pharmacists.
I used oral pills for six months to avoid pregnancy. I developed nausea and giddiness. So I
stopped it (OWEU-4)

She took tablets, which, we got from Chengalpattu, Medical College to space between first and
second births. She had developed vomiting sensation and poor appetite and so she stopped it. I
used condom whenever I had it. But I felt dissatisfaction in sex while using it. Also I have
teenage children so Ifind it difficult to use the-condom regularly. (YMEU-5)

E. Perceptions on abortion

A majority of never and ever users of abortion in the study opined that abortion was wrong and had
many negative health consequences like excessive bleeding, severe back ache and abdominal pain
uterus damage and in extreme cases it could also lead to death.

7

“Abortion is wrong and it is equal to a murder. It has wider health consequences I have known that a
woman had died of it. I also heard that women would have developed severe stomachache and
stomach burning sensation after the abortion. ”(YMEU-5

There were a few standard reasons, which almost everyone gave for why couples opted to terminate a
pregnancy:

•

The earlier child was still an infant

•

Children are grown up

•

To avoid a female birth

•

The economic situation of the household was very bad

•

The woman’s health was poor

•

Astrological reasons: it is considered inauspicious to have a birth in the month of ‘Chitirai'
(May, the hottest month of the year)

More than a quarter of the women (19/66), including both users and non-users, said that unwanted
pregnancy was caused by ‘non-cooperation from husband’ who did not take responsibility to prevent
pregnancy, and compelled women to have sex. Only 13 women held non-use of contraception as
responsible for unwanted pregnancy. Clearly, there is a perception that women would be able to avoid
unwanted pregnancy if only men abstained from sex when a pregnancy was not immediately desired.

F. Experiences of abortion users
Thirty-four women who had ever had an abortion are included in the study, 17 belonging to the
younger and 17 to older age categories. About two-thirds of the women (18) had had one abortion.
Eight women had undergone two abortions, and two women each had undergone three and four
abortions respectively.(a total of 52 abortions).
Whose decision was it?

In two-thirds of the 52 abortions (34), the decision to terminate the pregnancy had been taken by the
woman concerned. In a little less than half of these instances (15/34), the women had not been able to
get their husbands’ support for having the abortion, and had gone despite their lack of enthusiasm or
involvement. Instances of women going for abortion without their husbands’ explicit consent were far
more common among the older age group (11/27 abortions) than among younger women (4/25
abortions).
Already I had five sons and my husband was not co-operative with me. His second wife also had two
children. Taking in to all these I decided to abort and informed him. But he didn "t agree. Then I went
to my mother's home and had the abortions. My parents paidfor all the expenses (OWEU-14).
Eleven couples had decided jointly. Support from mothers and mothers-in-law were also often sought.

I first thought of terminating the pregnancy and told him. Initially he rejected my suggestion
and I convinced him later. Finally we both decided. My mother also agreedfor that.(YWEU-8)

8

Reasons given by women for having an abortion

There were a range of different reasons given by women for terminating a pregnancy although the
des ed°fmT °neS’ PredlCtably’ Were t0 limit
Size either b— they had ^ed thei
desired family size or for economic reasons; and to have a longer birth interval.

•» ■“

A
7 “a" ‘‘d“"

,n'mlk

‘XiX'lO^Sn^T011 reaS°n 8iVen by y°Unger W°men Was ‘econ°mic circumstances’ and
poverty (10 abortions). A concomitant reason given by some women was that they would not have
any social support during and after the pregnancy.
7
anf}Oritioni,n my first pregnancy because of my family's economic crisis. We were in a
TouL f
Poor. We took the decision with a heavy heart. There was no way we
could manage to have this child because we had no money and no family support. (YWEU-18)
'My abortions - I had two- were for economic reasons. When I told him of my pregnancy he
Than
pregnant in the hiSh season for business, what can we doWe run a
shop, both of us have to work. So he decided that we should terminate the pregnancy. Because
salesandourincom 0
^lday inthe shop durinS my pregnancy and that would affect the
sales and our income. He asked me to do and I did it. ’ (YWEU-7)
Another important reason given especially by the older age group (9 abortions out of 12 for this

to°—wom“

“

Where did they seek abortion services from?

mXttXaorXfi77r ’ W’re JX by rUral me<liCal

»ho had no formal

G._Abortion-use and gender power relations within marriage
Wejase the following as indicators of gender power relations within marriage when comparing the two
^hetheVhe
W3S WitH the COnSent of both (more equal power relations) as against the
Zuhss^'f8 tf°rCed
thC marria8e (unequal). Whether the women reported unhappiness
and dissatisfaction with the marriage (unequal)
4 X"’5”.!'
within marriage: joint (more equal), some

independently

“

W°m'n’S ftee<l°'” °f

9

decisions (less

•nd frecdom '» act

=4 Absence of non-consensual sex, of sexual violence and of any intimate partner violence.
Husbands’ co-operation in pregnancy prevention
Type of marriage and satisfaction in marriage
Overall, there does not seem to be any major difference between abortion users and non-users in either
in consent to marriage or in satisfaction with marriage as reported by the couples in separate
interviews. What is noticeable is the higher number of ‘love’ marriages in the younger as compared to
the older couples
Role in decision-making

The noticeable difference between abortion-users and non-users in women’s role in decision-making is
in the numbers who report a traditional division of decision-making authority, with men deciding on
all money matters and women deciding on all household matters, with 10/23 in the abortion-users
group reporting this as compared to only 5 of 21 in the non-users group.
Non-consensual sex, sexual and other forms of violence

The important difference between abortion users and non-users appears to be in non-consensual sex
and sexual violence, far more common among the former than the latter. Non-consensual sex and
sexual violence would by allowing women little control over their sexuality expose them to the risk of
unwanted pregnancy. Many of the women see unwanted pregnancy and abortion to be a direct
consequence of non-consensual sex, often accompanied by violence when the women resist.
I could have avoided my abortions but he didn’t co-operate with me (did not accept her refusal
to have sex) (YWEU-7)
Some women reported that their husbands compelled them to have sex saying that if there was a
pregnancy, they would pay for the abortion.

If I reject his desire to have sex, he says "It is me who will be meeting the expenses, if you
conceive you can go for an abortion. But he doesn’t realize the problems associated with
abortions. (YWEU-17).

There are numerous stories of women trying to avoid pregnancy but not being successful, leading to
unwanted pregnancy and abortions or sometimes, unwanted births. The men sometimes blame the wife
for getting frequently pregnant -'You get pregnant with a single touch'.
When I express reluctance for sex saying that I am worried about getting pregnant, he says, "I
will take care if it happens. If I object strongly he shouts, “Are you sleeping with someone
else? ” After my first childbirth he called me for sex with in a month. When I objected he beat
me. This is a regularly happening in my life. (YWEU-2)

An older woman who is currently pregnant, her fifth:
He is working outside the village and comes home once in 2 or 3 days. In that situation I am
not able to say no, even it is during the day. I have to accept it. If, I object, he shouts, "When I
am not at home, who else comes? I have to accept his desire otherwise I have to face beating
and shouting. This is happening in most of the women’s life.

If I give fear ofpregnancy as a reason, he won’t leave me alone. He says conception doesn’t
take place frequently. I am pregnant now. Everyone is talking about my getting pregnant after
having grand children, I am ashamed... (OWEU-17).
A young woman of 25 years who is experiencing her fifth pregnancy currently:
10

I had aborted two pregnancies; 2nd and 4th. I was very worried. I first decided to end my life
then finally I boldly decided to go for abortions. There was no other way. He said “you are
getting pregnancy with single touch". Fear and embarrassment in asking for spacing methods
and his compulsion in sex lead to three unwanted pregnancies and two abortions.
Even though men are responsible for pregnancy, Generally people speak it is a fault of women. They
say that “Men are good, women are foolish, emotional and looking for body pleasure. I felt very bad
when some had teased me saying that I won t leave my husband alone for a minute and my stomach is
always bulging (with a pregnancy) (YWEU-6).

Contraceptive use
Comparing the use of contraception by abortion users and non-users, we find that women who have
had an abortion have also tried to use a method of contraception some time in their lives.
The most common method ever used was the condom, which the men discontinued use or used
irregularly for reasons such as non-availability of regular supplies, interference with sexual
satisfaction, and costs. Reasons for discontinuation of the pill and the Copper-T were usually related to
side effects.

Husbands' opposition to use of any method of contraception was more common among older women,
although some of the younger women also mention it.

He is only responsible for the abortion, because first he prevented me to go for an operation
and then he beat me when I expressed my reluctance for sex. So again
’ it led to another
unwanted pregnancy and abortion. (OWEU-2)
He didn't want us to use any contraceptives and that is why it (the abortion) has happened in
my life. (YWEU-15)
Conclusions
We started out with asking whether and how gender power relations affect the choice of abortion to
space or limit births, and whether these have changed across generations. We had also wanted to
examine the differences between the group of never users and ever users of abortion in how gender­
power relations played out in the married relationships.
We find that overall; women have limited decision-making power within the household, even in the
younger age group. Men control most of the decisions. Women may have physical mobility, but these
are only for specifically sanctioned purposes such as taking the child to a health facility or to go to the
market. Women's efforts to participate in public activities cannot succeed unless their husbands gave
them permission to do so. We did not observe much of a difference between the younger and older age
groups in this respect. This appears to be because older women gain more autonomy as they begin to
be seen less as 'sexual beings'.

Discussion and communication on sexual matters seems to be still very rare, but when it did happen, it
was among younger couples. On the other hand, non-consensual sex and sexual violence was also
more common among the younger than in the older age group.

Non-consensual sex and sexual violence appears to underlie the need for abortions among many
couple, both young and older. Although women are well aware of their sexual rights and believe that
men ought to take responsibility for preventing pregnancy, the reality they have to contend with is
very different. Women go through one pregnancy after another, terminating when they can, carrying
unwanted births to term when they cannot.

11

There are many differences between younger and older couples who have had abortions. Older women
often had to make the decision themselves; many had little support from their husbands and had to
take their mothers, sisters and neighbours. They had to seek abortions from places that were
affordable, including traditional abortion providers. In younger couples, the abortion decision is
supported by the husband, who accompanies the wife to the abortion facility and pays for the services.
This is despite the fact that pregnancy was the consequence of sexual coercion on his part. Some
women's reports indicate that men may be taking abortion very lightly - as something they can pay for
and be done with. The frequent mention of poverty and economic considerations as a reason for
abortion in the younger age group, and also instances of younger women being compelled to terminate
their pregnancies is a rather disconcerting development.

What are the differences between never-users and ever-users of abortion, especially in terms of
gender-power relations within marriage?

The information above on contraceptive use suggests that non-users of abortion are equally exposed to
the risk of unwanted pregnancy as abortion users, or perhaps more so, other things being equal.
One of the features that distinguishes the two groups is that in the 'never users' group, more husbands
'co-operate' in preventing an unwanted pregnancy, taking responsibility for fertility control even
though they do not use condoms. This would explain the lower average numbers of pregnancies
experienced by the 'never users' group, and also its lower reporting of non-consensual sex and sexual
violence.
In the abortion-users group, while some initiative has been taken by men to use condoms, use is
inconsistent and irregular. Women are unable to use the pill and Copper T because of side effects.
Many women are also afraid to use a method without their husbands' explicit approval, because of the
fear that in the event of side effects, the men may not support their health care seeking. When efforts
to prevent pregnancy through contraceptive use fail, and men are unwilling to abstain from sex
irrespective of the risk of pregnancy, women have to rely on abortions to prevent unwanted births.
They do this at considerable risk to their health.

The most noticeable distinction between 'ever- users' and 'never-users' of abortion is the preponderance
of non-consensual sex and sexual violence in the former. Thus, what lies behind an unwanted
pregnancy is usually unwanted sex and the lack of power to say no. Many of the men appear to believe
that sex within marriage is their right, and that the women have no say in the matter.
So, interventions to prevent unwanted pregnancies would have to address the issue of sexual violence
within marriage as well as with making reversible contraceptives acceptable and available free of cost
regularly to young couples.

12

References
1. Johnston, Heidi Bart, Abortion and post abortion care in India: a review of
literature, Draft 3, December 1999, IPAS, North Carolina, and Agarwal Sapna,
Annotated bibliography on abortion in India, Health Watch Trust, 2000.
2. Singh KP and Singh R. A study of psycho-social aspects of MTP. Population
Research Centre, Department of Sociology, Punjab University, Chandigrah,
1991. unpublished report
3. A study on abortion in Varanasi, Uttar Pradesh. Parivar Seva Sanstha, New
Delhi, 1999.

4. Sinha R, Khan ME, Patel BC, Lakhanpal S and Khanna P. Decision-making
and acceptance in seeking abortions of unwanted pregnancies. Paper
presented to the International workshop on abortion facilities and post-abortion
care in the context of the RCH programme. CORT, Baroda, March 1998.
5. Gupte M, bandewar S and Pisal H. Women's role in decision-making in
abortion: Profiles from rural Maharashtra. CEHAT, Pune, 1997.
6. International Institute for Population Sciences, ORC Macro, 2000. National
Family Health Survey (NFHS-2), 1998-99: India. Mumbai, UPS.
7. Kulkarni PM, Krishnamoorthy S and Audinarayana N. 1996. Review of
research on fertility in Tamil Nadu^ Coimbatore, (India),Department of
Population Studies, Bharathiyar University. Unpublished monograph, p.29
8. Mishra US; Ramanathan M; Rajan SI. Induced abortion potential among Indian
women. Social Biology. 1998 Fall-Winter; 45(3-4): 278-88.
9. Ravindran TKS. Women's status and fertility transition in Tamil Nadu: An
inquiry into the interlinkages. Unpublished report, UNDP Project on Human
Development
in
India,
Centre
for
Development
Studies,
Trivandrum,Kerala, 1997.
C5B90SS9

13

VO \A - S"

Executive Summary: BVS Study ofInformal Providers of abortion

Introduction
After legal MTP was available in India, it was hoped that all other forms of abortions would

cease and this would bring down related morbidity and mortality. However various reports underline
existence of informal/criminal abortions. This study was done in a tribal area of Nasik district. It

confirms that people still seek 'other' methods of abortion, and for various reasons.
Material and methods

The study area belongs to northwest part of Nasik district, inhabited by Konkana, Koli, Warli,
Thakar tribes. The area has its own Primary Health centers and Community Health Centers, some of

them offering MTP facilities for last few years. Looking at the abortion needs, the MTPs done by
PHC/CHCs seem to be either underreported or too few. Induced abortions must be happening

somewhere else. There are also private practitioners in the area. It is known fact that many untrained

doctors offer MTP (illegally) and charge hefty fees. However, such doctors were not part of the study.

The study was undertaken with help of two trained researchers, both women. One of them had

close contacts in the community, which led to IAPs. The study spanned 5 months in fieldwork.
We used qualitative methods for this study. The initial listing was done through local contacts in

the area. The providers were approached and a semi-structured questionnaire used to bring out
information. FGDs were used to assess community understanding of the issues involved. In all 7

persons were identified and interviewed as abortion providers. All of them but one shared information

and anonymity was observed. The seventh interview was abandoned halfway, but results have been
recorded. For reasons of ethics, acceptors were not included in this study.

Findings
Not every village has an abortionist. Instead some villages and abortionists are popular in the

community. They were 3 men and 4 women. Education ranged from none to 7th, all of them from

Scheduled Tribes, and most learnt it from a family source. The range of years of operation is 8-29

years. Most but one used herbal methods for abortions, the only other method was stick insertion. The
usual client is the unmarried woman/girl or out of wedlock pregnancies. They do it once a twice a

month, and earn about 200-500 Rs per case. Tn general, more the need for secrecy and more the
weeks, higher the fees. As is common, they practice at home, or rarely at client's home. The methods
reportedly work, but client-confirmation was not possible. There was one death by one of the providers,

and the case is still pending. However the informal abortion trend seems to be declining.
The Community confirms most of these findings. The FGDs bring out the weakness of the

public MTP facilities--lack of secrecy, costs, and the frightful traumatic methods (curettage). Now they

C:\My Documents\Qualitative Studies\Draft Sharing Workshop\ABSTRACT-Shyam.doc

1

Executive Summary: BVS Study ofInformal Providers of abortion
use it mostly for social problems. PNDT was not the issue in these community. Failure of contraceptives
was never stated as a reason. We think it is a non-issue among tribal people.
It is unknown how many acceptors land up in hospital for complications. One of the FGDs

throws light on this aspect. "If complications occur", says the woman, "we take her to a PHC but never

reveal that she has undergone an abortion and just talk about bleeding". This means that at least some
tribal women reporting bleeding may have actually undergone informal abortion. If it is a herbal

method, the doctor will be clueless about the cause.

Ethical issues
Ethical issues about research on illegal practices presents a major dilemma. In the case of this
study, informed consent was a halfway affair. All of them took the interviewers as clients and shared

information till they were told that this was a study. Because of presence of close contacts the interview
could proceed. But should written consent be made a precondition none would have shared
information. The study group decided to document the information but protected the identities

throughout.

Conclusion and recommendations
Informal abortions exist, despite 30 years of MTP act and public facilities, at least in tribal

areas.

The study gives an impression that lAPs are more community friendly (than public MTP centers)

and herbal methods are more acceptable than traumatic methods of curettage. On the cost side,
doctors at most public MTP facility charge about the same money (!) but people find the terms of
payment with lAPs as being easier; they can pay them in installments, often after the abortion. One of
the stated reasons of IAP preference is the fear of getting a bad name if one does it at the public MTP
facility. Since most IAP clients do it for social reasons, this becomes a crucial issue. At IAP's home, it is

often the only client at that time, while at a PHC/CHC 40-50 people are present at any OPD and
servants are more acquainted with local population. Thus three advantages of (herbal) lAPs stand out:
better secrecy, terms of payment and less traumatic method. If one wants to 'weed out' abortion

herbalists, these three factors need to be attended.
What may be lost in MTP legalities is that herbal methods are still around and people aie using
them. Ayurveda identifies several herbs for abortion and more studies are necessary to bring them to

mainstream or weed them out for confirmed risks. Between legal MTP and injurious criminal abortions

that are commonplace with quacks, there is a softer option available through herbalists. The herbalist's
situation protects the much-wanted secrecy and the basic costs are not high. The tradition is easy to

learn and give. The Medical research community needs to put an ear to this ground and make amends.

C:\My Documents\Quantative Studies\Draft Sharing Workshop\ABSTRACT-Shyam.doc

2

STUDY ON INFORMAL PROWERS FOR ABORTION CARE IN RURAL KARNATAKA
VGKK
EXECUTIVE SUMMARY

aTXrt“~pXed bv^ZT' diS“

Kar"a“a h3S 3

USi"9

'»

undergone abortions were married and onN 18»/ were
population ba„e undergone abortionsXoes J .apT^ • X

82%
“ am0"9 n°n“riba'

haV'n9

rrom IAP s. 44/o of these abortions were conducted at the hospitals and the

Executive Summary: Abortion Study-Karuna Trust

s
1

remaining were conducted at home/at provider’s location. The researcher while acknowledging the statistical

insignificance of these results intends only to demonstrate the abortion trends in the population through these figures.
A total of 20 FGD’s with women, men, adolescent girls, ANMs and 32 interviews with informal providers were conducted

A careful analysis of the data collected revealed that women seeking abortion in the area were doing so for the following
reasons:

1

Non-tribal areas

•

Spacing of pregnancies

•

Did not want any more children/ and to reduce the family size

•

Life threatening pregnancy

•

Widow, divorcee and unmarried women for social reasons

•

Failure of contraceptives

•

Fear of having a girl child

•

Poverty

•

Poor health of the mother

•

Might spoil the beauty of the mother

•

Family planning services unavailable

The analysis reveals that women in non-1■tribal areas choose the services of an informal provider for the following reasons:

•

Confidentiality being maintained

•

Less expensive

•

IAP being females and hence no hesitancy about seeking services

Executive Summary: Abortion Study-Karuna Trust

2

•

Belief that there is a low rate of complication

Analysis discloses women increasing prefer the hospital services for abortion

between Rs 500-1000/- at the private hospitals.

services. The charges vary anywhere

t?eXor,0 "'“T infOrma,iOn ab0U' 'he 'AP 0Pera,i"9 in 'he a,ea- ThG adOleSCe"'9irb tlad »on
bosoJs

,CeS'

'“e kn°W'ed9e ab0Ut 'he

°f infOrmal SerVice

a

revealed that

hospital services are preferred for seeking abortion services.

Tribal areas
•

To reduce the family size

•

Divorcee

•

Unmarried

•

Widow

•

Spontaneous

•

Spacing of pregnancies

lAP’s are illiterate and do wage labor,
community.

treat common ailments, usually over 35 years of age and are familiar with the

Some of the reasons to seek the services of an IAP are as follows:

•

Confidentiality

•

Less expensive

•

Unmarried

Executive Summary: Abortion Study-Karuna Trust

3

•

Widow

•

Divorcee

INFORMAL ABORTION PROVIDER

CATEGORISATION OF IAP

•

Traditionally trained women

•

ANM/Rtd ANM

•

Trained dais

•

LHV/Rtd LHV

•

Med Doctor (untrained in MTP)

•

Ayurvedic Doctor

The IAP m the study area are traditionally trained women, dhais, and ANM’s. These informal providers are familiar and

are preferred over the formal systems due to the cost, confidentiality, and access issues. There are various factors

responsible in making the choice of the provider and family dynamics are key in decision-making process. The familiarity
of the IAP among the community makes them an easier choice over the formal system as well. Majority of the informal
providers use a green coloured medicine termed ‘Kashyas’. The IAP conduct the abortion within ,12-16 weeks and refer to

Executive Summary: Abortion Study-Karuna Trust

4

hospital after 16 weeks. They charge money for the seryices and costs would be based on duration of pregnancy and
ranges from 100-200/-.
While it is interesting to note that the abortions conducted by lAPs have had very few complications; the reasons behind
them could well be that they often terminate pregnancies in the first trimester usually with herbal medicine and less so

with invasive procedures. This timely intervention along with a lower invasive intervention probably explains the lower rate

of complications in their services. Of late the lAPs have begun to take women even in the first trimester to hospitals and
receive remuneration from doctors. Women in the study area have now begun to prefer the hospital services, due to an

increase in awareness. This has led to a decreasing breed of informal services providers in the study area.
While, we observed that there is a declining trend in the informal abortion providers, there is yet a considerable amount of

abortion services undertaken by them. There is however a gradual shift towards the scarce formal system for seeking
abortion services. This is explained due to an increased awareness and improved physical access to the formal systems

Key findings

Executive Summary: Abortion Study-Karuna Trust

5

Reasons for seeking services from Informal providers
-

::

J

-

....

..

■

■

•.

•

Confidentiality about the abortion

•

Less expenditure

•

Abortion seekers are not hesitant since IAP are usually women

•

Low rate of complications in the previously conducted abortions by the
IAP

Executive Summary: Abortion Study-Karuna Trust

6

Informal abortion providers

•

Familiar within the community

•

Traditionally trained by the parents/grandparents

•

Terminate pregnancy with herbal medicine (Green colored

medicine/Kashayas)-Usually in First trimester 8-12 weeks

•

Invasive procedures by using sticks

•

Charges based on duration of pregnancy

•

4 weeks 100/-, 8 weeks 200/-

•

Sometimes receive rice/wheat etc for services

•

Complicated cases if any referred to the health center

•

Very few complicated cases reported so far

•

IAP s of late take the cases to hospitals and receive remuneration

Executive Summary: Abortion Study-Karuna Trust

7

Decreasing breed of lAP’s!

•

■

With increasing awareness, women prefer hospitals to undergo

abortions.
•

Informal providers take women to hospitals and receive remuneration
from doctors.

•

Decrease in number of informal MTP service providers.

The study documents the pathway to abortion, issues related to access and availability of both the IAP and formal
systems. It examines the sequence of events in decision-making process in abortion. While it examines the spectrum of
the IAP practices, it documents the existing gap in the information about the unsafe perception of IAP. The study also

documents the shift towards the formal systems and gender preferences responsible for seeking abortion services as

well.

Executive Summary: Abortion Study-Karuna Trust

8

Pathway to Abortion

Realisation of unwanted pregnancy

Home made concoctions
V

Decision-making

Societal values/implications+++
Consent/Family decision++
MaIa rpsnnngihilitv+

Community,
Access
Seek the services of the provider

Formal
provider

Informal provider

Increasing awareness of formal sector
Improved access
Increasing choice of preference
Cost of about 500-1000/-

+ Denotes level
of influence in
decision making

Confidentiality being maintained
Less expensive
IAP being females-less hesitancy
Belief of a low rate of complication

Executive Summary: Abortion Study-Karuna Trust

9

Sequence of events: Informal Abortion Providers
Realisation of unwanted
pregnancy

Home made concoctions

Community proximity,
Increased access

\z
Informal provider
Rationale for Choice

Herbal medicine/less invasive

Confidentiality being
maintained
Less expensive
IAP being females-less
hesitancy
Belief of a low rate of
complication

Complications
V

Health centre/ Secondary
hospitals/Private hospitals

Executive Summary: Abortion Study-Karuna Trust

10

VaJ W1'

Executive summary

*•

•..SljMSTW

The area chosen for this study was Tigri a resettlement colony in South of Delhi a home to 15.000 people.
The population comprises of majority of Hindus with a sprinkling of Muslims, Sikhs and Christians. The
socio economic status of this community falls in the low socio economic bracket with an approximate
monthly household income between Rs. 2000 to Rs. 8000. Majority of the people are daily wage earners
including skilled and unskilled workers, few of the residents are also working as government employees
and some own shops within the community itself.
Health services are available to the community through 2 neighborhood hospitals that are in the vicinity of
2-3 kilometers. There are other health care providers both formal and informal including non-MBBS
doctors, quacks, local medicine men, practicing in the community itself.
Findings
Community is unable to clearly distinguish informal from formal but award ‘recognition’ to some
providers as qualified based whether or not framed degrees and certificates are displayed in file clinic.
Lack of clarity is visible also in file contradictoiy opinions expressed by different community members on
some of the providers in file community. The providers include daais, nurses, doctors (not qualified), and
chemists, women who have worked with doctors or with daais and leamt abortion practices.
Informal or untrained abortion providers are seen as individuals practicing abortion with some minimal
training or experience or exposure to the ‘art’. After working with a daai or a doctor the individual has set
up her own ‘shop’ and is now doing abortions.
The procedures adopted for aborting a pregnancy include giving herbs or medicines (capsules) or home
made preparations (kanhha) orally, to inserting ‘medicines’ in the vagina, to massaging the abdomen and
finally even invasive procedures using instruments.
The sequence of actions include waiting for 2-3 days after the date of menstruation then during or after
these 2-3 days go for some home made herbal preparation to start periods, few women who do not take
these herbal.preparations go in.for a test for which they go to doctors. Then sharing with her husband or
any other family member of the family and then going in for abortion.
The decision of going in for abortion is of either husband or wife solely sometimes, mostly both ofthem
take the decision together or sometimes the parents (of the husband) take the decision. In the case of
unmarried girls the girl and her parents would take the decision. Woman’s decision to go in for an
abortion is influenced by factors like desire to limit family size, male preference, number of live children
and their state of well being. Unmarried girls and single women choose to go in for abortion due to the
fear of defamation.
The choice ofthe provider depends up on various factors like the service charges, social distance from the
provider, fear of defamation as in case of unmarried and single women, fear of the instruments used for
abortion, faith in the provider. The provider in case of unmarried girl and the single women chosen is
usually out of community and the preference is a formal provider as they do not want to take any risk of
defamation, which might happen in case the care provider belongs to the community. Money in such
cases is not considered much. Another reason of going to the community-based provider is the social
distance from the formal provider.
The protection issue is seen as something relevant only in the event of a mishap. This is due to lack of
understanding that these informal providers are practicing illegally. This is also linked to the view that all
abortions are illegal. The provider and client are actually
Operating hand in glove....into this together and that is the clients’ perception of the situation. The
informal providers enjoy and maintain positive and congenial relations with the clients. They are viewed
by clients as providers of an important service and that too at low cost. Thus clients themselves become
their protectors and allies. They use a range of strategies to stay hidden and do not get ‘discovered’
because they practice without much visibility and only by word of mouth within a limited network.
Another strategy some of them use is that they practice out of either their homes.

Abortion is seen as a fairly simple procedure for which skills can be acquired by working as an apprentice to a
qualified and trained person (daai or doctor). In any case there is also a difficulty in distinguishing trained from
untrained or qualified from unqualified.

Informal providers take advantage of it to stay undiscovered and they might even practice very boldly and within
lavish set ups to dupe the community to believing that they are well qualified.
In the event of mishap they protect themselves through an economic tie up with formal providers as well
as police. The former gets a case and in fact might even be paying a commission to the informal provider
for the referral while the latter receive bribe to hush up the case. This is further supported by the clients
high level of legal ignorance.
The community based provider’s work with caution; there are precautionary measures that are taken care
of by them which include leaving no proof of services provided (like receipts etc.) also they have their
own referral system which is used in case of some complication.

The formal provider has her own referral system by which she sends her clients seeking abortion to
different set-ups including hospitals and different clinics. According to the provider there are iw informal
providers who functions in the community. Women / girls seeking abortion go out of community to near
by hospitals and clinics. The formal provider has a limited understanding of services. The formal provider
denies any linkages between the formal system and the informal providers functioning in the community.
The formal provider views the services provided by the informal providers as illegal, but at the same time
she feels that these providers enjoy the confidence of the community.
An informal provider (chemist) dispenses/sells medicine to women who report of missed periods or
unwanted pregnancy. These women not necessarily come with doctor’s prescription; these women may or
may not come with doctor’s prescription. Based on the gestation period the provider also decides the
quantity of medicine. The provider feels that these medicines work effectively as reported by the clients to
him. For those where these medicines are not effective stronger dosages are recommended and even then
if the pregnancy is not terminated they are referred to some other doctor or clinic. The chemist also
reported having linkages with other chemists within and in the surrounding communities. According to
him abortion is not a right thing and he also believes that these medicines that are used for abortion are
not good for health especially for the young girls, these medicines may lead to infertility later. He also
believes that some contraceptive methods should be used instead. About the untrained community based
providers the chemist feels that they are doing an illegal work.

vOH - •?,-

Executive Summary: Study of Post Abortion Care Through Public Health System
Academy for Nursing Studies
1. Introduction:
Deciding to abort a pregnancy can be difficult for a woman. The slow process of
decision making delays abortion seeking behaviour and increases the risk to the woman’s
health. A woman may herself decide to abort a pregnancy. But often the decision making role
is taken by the husband, mother-in-law or other household members. Social norms laid down
by community play a vital role in the decision making process. Community health care
providers or other medical personnel also play an influencing role in a few cases.
The role of peripheral health workers - ANMs - is extremely limited in the area of
abortion services. They are neither authorized nor trained to perform abortions. Unlike their
counterparts in neighbouring countries such as Bangladesh, ANMs in India have a passive
role in abortion services. ANMs or other mid-level providers are not authorized to perform
even MVA or MR. The ANM does not usually live in the village and so women hesitate to
seek these confidential services from her and often go to illegal and unsafe providers. These
abortions are not recorded or reported.
Post abortion services for management of post abortion complications are thus of
particular relevance in India. Abortion and post abortion services through the public health
system need to be expanded in order to improve access to women. The role of midlevel and
peripheral service providers needs to be re-examined, explored and expanded. The quality of
abortion services in the public and private need to be improved.
This study is a qualitative multi component assessment of perceptions, problems and
experiences of 40 women who had abortion (27 from a government hospital, 13 women from
a nearby community) and 17 service providers. The women who had abortion at the
government hospital were followed up several times for six months after the abortion to
record their post abortion experiences and elicit information about follow up services
provided by the public health service providers. Interviews were also held with 13 women
from three villages who had an abortion during the past 12 months. Service providers working
in the hospital and the community were interviewed
interviewed for
for their
their experiences
experiences and
and problems.
problems.
2. Study objectives:
•

Do women receive post abortion care and counseling from the public health service
providers? What is the percentage of women who receive services of ANM or other
service providers? What is the content and quality of these services? What are the
factors that hinder women to actively seek the services of public health service
providers during and after abortion? - economic, gender, social?

•

What do women expect from service providers in relation to abortion and post abortion
care? What factors hinder the provision of post abortion services by ANMs and other
service providers? How sensitive are service providers and the health system to gender
concerns such as confidentiality, decision to seek services and privacy?

•

What is the relationship between abortion, MTP and family planning acceptance? What
are the differences in perceptions between postnatal and post abortion care? Are women
perceived and treated differently?

•

What is the impact of not receiving service from the public health system on the health
of women (economic and health consequences)? What needs to be done to improve the
provision of post abortion care and counseling?

Framework for post abortion care and follow up: The post abortion follow up care framework
was prepared based on technical inputs from experts from different fields such as obstetrics
and gynecology, midwifery, gender studies and public health. It was decided to have four
interactions with each woman who had an abortion: Immediately after the abortion at the

hospital, within two weeks after abortion at home, within two months after abortion at home
and within six months after abortion at home. A list of services to be provided to the woman
during each of the interactions was drawn up. The interactions with the woman assessed
whether these services were actually provided to her in case the service provider visited the
woman during the specific periods after her abortion.
3. Design of study:
Study area and components: The study was conducted in one backward district of Andhra
Pradesh (Medak). The study consisted of four components - prospective follow up of 27
women who had abortion in a government hospital, retrospective analysis of 13 women who
had abortion during the last 12 months, interviews with 17 service providers and observations
of two health facilities.
Table 1. Summary of sample included in the different components of the study

Women who had abortion_____________
Prospective component — Follow up for six
months from hospital: T1 women who had
abortion in a government hospital

Service Providers
Hospital staff: Four
doctors and three
staff nurses
Retrospective study in the community: 13 Peripheral staff:
women who had abortion in the preceding Nine ANMs and
one year identified through household one Health Visitor
survey

Facility____________
One
government
hospital where MTPs
are being conducted.
One PHC

Tools for Data Collection: The instruments for the follow up component were designed with
the follow up framework as the guide. Four interview guidelines were used for the follow up
component - one for each interaction. A separate interview guideline was designed for
interaction with the women in the community from the three villages. Service providers were
interviewed with the help of an interview guideline. A facility checklist was used for assessing
the hospital and the health center.
Ethical and gender issues: Only one person - a qualified senior ANM was used throughout
the six months for recruiting women for follow up in order to ensure confidentiality and
continuity. The entire study was explained to the woman before the abortion and repeated
once again before she left the hospital. If she agreed to participate, her complete address was
noted down and time and place were set for the first follow up visit. Debriefing sessions were
held with the field investigator after she returned from the visit. This ensured that no one
knew the woman who had abortion.
4. Findings from the prospective component of the study
Out of the 27 women who were followed up, 15 had induced abortion and 12 had
spontaneous abortion. Most of the women were from poor socio economic groups. The cases
of SG and SF are illustrated here.__________________________________________________
Socio economic status of women - Case of SG and SF
SG’s husband deserted her. She is currently living with her mother since she does not have
anywhere else to go. SG’s mother rented a small room for Rs. 100 per month since SG’s
brother did not want them to live with him. The room does not have electricity or water
supply. Both of-rhem accept any work that comes their way and earn about Rs. 20 each per
day when they get work. They are not able to buy enough food with the money they earn. SG
and her mother are worried that they will have to move out of this room since it was
becoming difficult for them to pay the rent. SG became ill after her abortion and was too
weak to work in the fields. They owned only afew clothes and vessels.
SF is a 30 year old Muslim woman with seven children. She and her husband are daily wage
labourers who together earn Rs. 70 when they do get work. In addition they have two goats.
The family consists of nine members including two adults and seven children. When one of
them becomes ill and is not able to go out to work, the family suffers because they do not
2

have enough to feed everyone.

Age and type of abortion: Majority of the women were young with 16 out of the 27 being
less than 25 years. Women who underwent induced abortion were slightly older than those
who had a spontaneous abortion. The mean age of women who had induced abortion was 24.8
years compared to 21.5 years for those who had spontaneous abortion. Four out of five
women who had induced abortion had it in the first trimester.
The three women who delayed seeking abortion services till the second trimester did
so for reasons such as not suspecting pregnancy, health problems or fear of social
repercussions. The examples of AA. NM and SF are described below.

Why do women delay seeking abortion ?
AA did not expect to become pregnant since she had undergone tubectomy the previous year. She
already had four children. But she had all signs of pregnancy including steadily increasing
abdominal size. AA suspected her pregnancy as a tumor. She went around clinics and hospitals for
treatment for the suspected tumor. It was confirmed as pregnancy when she was 14 weeks
pregnant. This news came as a shock to her. She was ashamed since she felt that pregnancy inspite
of tubectomy was her fault and somehow depicted her as a promiscuous women. She did not
approach the ANM. Finally she approached the hospitalfor abortion at 16 weeks.
NM was an 18 year old unmarried girl. At first she did not think it was pregnancy, though she
feared it because of her sexual relation with a boy next door. She confided her fears to her sexual
partner but he refused to accept responsibility. She was compelled to inform her mother. Her
mother requested him to marry her daughter but he refused since he belonged to an upper caste.
NM and her mother went to the hospitalfor aboriton when she was 16 weeks pregnant.
SF was suffering from hypertension even before she became pregnant. She already had seven
children and did not want any more. She went to the PHC for oral pills but the ANM did not agree
since her blood pressure was high. She went to the government hospital for tubectomy but the
doctor advised to wait till her blood pressure was normal. He gave her some tablets and asked her.
to come back later. In the meantime she conceived. She approached the government hospital for
help when she was 20 weeks pregnant.

3

Table 2. Socio economic and reproductive health profile of the women
Socio economic profile of women
Literacy and education
Illiterate
Primary education\ just read\write
Studied upto high school
Studied above high school

2

Occupation of women
Housewife
Daily wage labourer
Own trade\farm
Others

Freq

Reproductive health profile
Present marital status
Married
Widowed/ separated
Unmarried

22
1
4

14
9
3
1

Age at marriage in completed years
Less than 15
15-17
18-20
Above 20
Unmarried or missing information

8
4
7
3
5

Occupation of husband
Daily wage labourer
Own trade\farm
Service\employed
Not mentioned\Not applicable

9
7
6
5

Age at abortion in completed years
Less 20
20-24
25-29
30 and above

5
11
7
4

Caste
Scheduled caste
Scheduled tribe
Other backward castes
Others

13
3
3
6

13
7

Religion
Hindu
Muslim
Christian
Others__________
Type of House
Kachha
Pacca
Semi pacca______
Number of rooms
One room
Two rooms
Three rooms

13
11
3

Household size
Between 2-5
Between 6-8
Nine or more

13
11
3

15
7
3
2

4
18

Freq

Duration of pregnancy at the time of
abortion in weeks
Upto 12
18
13-16
5
17-20
3
More than 20_____________________________ 1
Number of pregnancies
First pregnancy
8
Second pregnancy
6
Third or more pregnancies
13

Number of abortions
One
Two
More than two__________
Number of childbirths
None
One
Two or three
Four or more____________
Number of living children
None
One
Two or three
Four or more

24
2
1

11
4
6
6
11
4
6
6

Order of pregnancy and number of children according to type of abortion: Women who
had induced abortion tended to have more living children. Five women who had induced
abortion had four or more children compared to only one who had spontaneous abortion.
Table 3. Order of pregnancy and number of children according to type of abortion
Spontaneous
Induced
Total
(n=12)
(n-15)
First pregnancy

4

Second

4

2

Third or more

4

9

No living children

7

One child

2
4

4 (unmarried)

4 (unmarried)

2

8

6

13
11
4

Two or three

______________ 2
4
6
Four or more
______
1
5
6
Reasons for abortions: The commonest reason for induced abortion
was inadequate
contraceptive information and services. Women said they had to go for abortion because the
previous child was 1too young. One of these said that the pregnancy was an obstacle for her
going for higher education. Only one woman expressed reservation
the use of spacing
------- against
-c----------methods. AA ffek
_,A shameful of becoming pregnant after tubectomy. Four of them came for
abortion because of illegal relationship. One girl was the victim of rape.
Women’s experiences of post abortion problems and complications: Seventeen women
said they faced complications within two seeks. But the number of women with complications
rose to 21 between two weeks and two months.
Psychological stress of abortion: Abortion procedure itself is involved with pain and
unhappiness. If other factors such as social stigma, religious belief and economical burden are
also associated with the abortion, the stress increases. Women who undergo abortion under
confidential conditions face severe trauma. Stress also accompanies spontaneous abortion
when pregnancy was strongly desired.
c°st of abortion: Most of the 27 women in this study selected the government hospital for
abortion because they were too poor to go to private hospital and because they thought
government services were free. But after coming to this hospital when doctors charged fee for
services, women and families struggled and went back to the village and got the money facirm
so many difficulties. The average fees that women had to pay the doctor for abortion in this
ospital was Rs.612. Doctors charged money from all women (except two) irrespective of
their socio economic status and type of abortion. Most of the women had to borrow money at
5 ^interest. Some had to sell their assets like jewelry, cattle etc. Apart from financial costs,
abortion affected the work and livelihood of the women and their families. Sometimes they
lost the work they were doing due to absence. Women who were daily wage workers (such as
and SG) suffered the most because they could not work and earn to feed themselves and
their families-Sometimes they could not work in the petty trade and so lost the small business.
1 he case of JD depicts these harsh realities.
Post abortion contraception: Among the 14 women who were not using contraception at the
end of six months four were unmarried girls. Four of the remaining ten women wanted to get
pregnant. One was scared of operation (AS who gets the spirit).
Women who have four or more children and yet do not want to use modern
contraception: Some women like ZB who completed their desired family size did not
undergo sterilization or use any other form of contraception because of their beliefs ZB is a
Mushm woman with four children. She feels that it is not right to use modern contraception
She prefers herbal medicines. Another woman AS has four children but is afraid to use
contraception for fear of the goddess who might visit her while the operation is under way
For both these women felt that repeated abortions were their only answer.
Abortion used as contraception: Six women used abortion as a spacing method. All the six
^d'n^ucedportion. Four of them aborted because their last child was too young at the time
ot abortion GM had one daughter who was five months. MT had one daughter who was
seven months. RD had two children - one son and one daughter. The youngest child is a girl
and sire was eignt months old at the time of abortion. ZB has four children - two boys and two
girls. The youngest child is a daughter and she is one year old.
Gonception after abortion: Eight women who had abortion became pregnant within six
months after the abortion. Among these six had suffered from a spontaneous abortion and
Zdl?
A1m°nJg the remalnlnS two, SR had undergone induced abortion but was
raid of infertility and so desired to become pregnant. SV was a widow involved in extra
marital relation and did not have social access to contraceptives.

5

Role of ANMs and other service providers: Only three out of the 27 women (AM, ZB and
GM) were visited by an ANM within two weeks after abortion. ANMs visited three women
within first two weeks, four women between two weeks and two months and two women
between two and six months after abortion. ANMs checked for fever, discharge, abdominal
pain bleeding and burning micturition. The women said that the sister enquired about their
well being, did a physical check on them, and reassured them. All the women expressed
satisfaction at the visit of the ANM . One of the ANMs looked at the prescription slip given
be
at.the hosP'tal and said that she would get the necessary medicines for her. One
of the ANMs also gave advise about post abortion care, need for food and rest. One of the
three advised the woman about family planning methods.
Reason for selection of the government hospital: Most women who belonged to low socio­
economic group gave low cost in government hospital as the reason for selecting this hospital
10 a rew women, this hospital was convenient because mother’s place is near to this hospital
conf beytCa,nf haVACkC°mplcte rest at her P'ace- SV elected this hospital purely on the basis of
confidentiality. Abortion services were available in her village. But someone might come to
know if she gets abortion done in that hospital and so she traveled to this hospital
Doctors who conducted the abortion: Though there were three doctors in the hospital and
all of them were involved in providing abortion services, the male doctor had conducted more
a o ions than the two female doctors combined together. Moreover, he conducted all the four
unmarried women s abortions and most of the induced abortions. The two female doctors did
more spontaneous abortions compared to the male doctor.

rLTX R^^ef^Ur^eS u She atten,ded in ,hiS StUdy She c^arSedfee for only twowon^en
(average Rs. 875). She did not charge anythingfor the other two cases because they belonged to
low socio-economic group and they requested her not to charge, as it was a government hospital.

MTPTrn^- SeVTu yearS experience,as a doctor- She not a gynecologist and did not undergo
^Ze7not8'rn d
at home besides irking in the government hospital. But
studv ShZhnraf ab°r‘lons l" her Pr^‘e clinic. She attended eight of the 27 cases in this
qa
accordinZ t0 the ^omen s socio economic status. Her average fee is Rs 637.
Retakes up abortion cases even upto 20 weeks ofgestation.
^nr,f!.fatSerliOr malf d5ClOr' He iS not a gynecolo8is‘- He ‘ives in the hospital premises and
oonducts deliveries and abortions regularly. His charges are high and range from Rs. 300 to Rs
JOO- He insists on the money being paid in advance. One of the cases (NM) went to him for
°n 717' He 8aVe h7r lnjectlon t0 induce the abortion and did not do the D&C till NM's mother
pai k money to him early next morning. He charges less from familiar women - Rs.300 or to
hose referred by other doctors (JK). He charges more from unmarried cases. For example he
^dbel^dT16”'^"1 7r\"',°7er even thouSh he was informed that BMwas a victim ofrape
and belonged to very poorfamily. BM’s mother had to pay him Rs. 1000for the abortion.
dUPP°rt t0 Tmen undergoing abortion: HusbandTmothers^ mother-in-law
huXI nW°m en Und"rg01ng abortion- TweIve women said they first approached their
husbands or the sexual partner to discuss the problem and decide about abortion. In some
27SwomeTfin^PPr°a leid^61r .T*61'5
W mothers-in-'aw (6) for support. Only one of the
27 women first approached health personnel for advise and support.
Role of husband: Husbands were a support to women specially in nuclear families and
women who opted for induced abortion. This was also true for the three women who had premantaJ or extra-marital sexual affair. Out of three women who were involved in premarital
sex, two got some support from the boys who were involved.
6

In the case of the BK the man involved helped financially for meeting the expenses of
abortion. He did not take her to the hospital or visit her at home.
In the case of PD, the married man who was involved with her bore the expenses, went
with her to the hospital for abortion.
NM was not so fortunate. The boy involved in the affair totally refused to help and even
denied the relationship.
SV was a widow involved with a married man. He bore the expenses and accompanied
her to hospital for abortion.
Role of mother: Mother was always available for support, even if she was not the first to
know about the abortion. In the case of NM, the mother did not reveal her daughter’s
premarital relation to the father. She told him that their daughter had abdominal pain and the
doctor said it was a tumor. BK and her mother also did not reveal BK’s involvement with
another man whom she met while working in the field. The man gave money and the mother
managed the abortion. In the case of two women(BM and SG), there was no man involved at
all. In both these cases mothers played the key supportive role - financially and emotionally.
In the case of BM who was the victim of rape, the mother managed the situation including
abortion and post abortion complications without revealing anything to the father. In SG’s
case, her father died and husband left her. Her brother refused to have anything to do with her.
It was only the mother who took care of her. Mother continued to work so that she could take
care of her ‘unfortunate’ daughter.
Role of mother-in-law and others: In many cases the mother in law played the key role in
decisions and support. In the case AA, mother-in-law gave total support. In fact it was her
decision that AA should have an abortion because she had four children and tubectomy had
failed. Family support was least forth coming in the case of PD and SV who were involved in
premarital and extramarital relations. After knowing about the abortion parents and all the
family members were angry with PD for involving into premarital sex.
5. Findings from retrospective study of women who had abortion :
This report pertains to 13 of these women because twp of the women who had the
abortion in the government hospital were included in the follow up study and one interview
could not be conducted as the woman left the place. The sample is too small to give any
generalizations or conclusions. But it does provide useful insights into women’s experiences
and the quality of services in the periphery. Since it was a community based study, there are
limitations and problems in identification at every stage - total population, female population
aged 15-49 years, childbirths and abortions in the previous year. This has resulted in gaps in
information about the women.
Majority of the women belonged to lower socio-economic strata with low education
and income levels. Seven women and six husbands were illiterate. Majority of the women
and their husbands were daily wage labourers and lived in large families in small kacha or
semi pacca houses with one or two rooms. Four of the 13 women had more than one abortion.
One woman (RM) had three pregnancies and all three pregnancies ended up in abortion. All
thirteen women said they planned and wanted pregnancy and all of them said that they had
spontaneous abortion. Even after probing they did not reveal facts about induction of abortion
at home or in the village.
Out of thirteen women six had abortion at home and the remaining seven women went
to hospital after bleeding started and the rest of the process was conducted in the hospital.
Most of the women approached mother, mother-in-law or husband for support related to
abortion. Eight women said that they approached a health service provider (government or
private) at least once either for abortion or after abortion care and advise. Other women
selected health facility based on familiarity of the service provider or reputation of the service
provider in conducting abortion. Eight women approached doctor directly for abortion. Seven
women said they received immediate treatment and five others said they were treated
respectfully at the hospital. Six out of 13 women underwent scanning, two women had manual
7

examination and some women said they also had BP, blood and urine tests done. Out of the
eight who visited hospital for abortion four were satisfied with the services given at the
hospital. Five women were advised by doctor to take rest and eat good food. One of the
women was advised not to have intercourse. Two women reported bleeding, and others
reported general weakness, abdominal pain, leg pain and headache. After abortion three
women changed the doctors with the hope of getting better treatment.
Attitude towards service providers: Out of thirteen women three women said they were
unsatisfied with the village ANM, five of them said they know ANM but did not know about
her activities, three women said they do not know their ANM, one woman said she heard that
ANM gives good services and one woman did not respond. PM said ANM is more interested
in family planning operation cases and she visits houses only for that purpose. Only one
woman said that women approach ANM for abortion in the PHC. Three women said ANM is
aware about their abortion. One woman said that she went to ANM for help but ANM refused
to take the case. Most of the women said they expect the abortion services to be provided free
of cost in a nearby government hospital.
Abortion proved to be costly for most of the women. Some women had given financial
reasons for not approaching the hospital. One woman (PM) said that she discontinued
treatment due to high abortion fee. Another woman (GY) said she could not have complete
checkup due to financial constraints. GY also complained that she had to tolerate the rude
behaviour of one staff in one government hospital because she could not afford to go to
private hospital. Abortion was a stressful experience for most of the women and their
families. The mother, husband and mother-in-law gave support to women. RM and her family
were eager about the pregnancy but she had abortion this time too. It depressed everyone. Her
mother took RM to her house and gave her complete rest and suggested RM to maintain some
gap between the pregnancies for sometime to avoid abortion.
6. Findings form interviews with service providers:
All service providers working in the selected government hospital and community
primary health centre were included in the service provider’s sample. A total of 17 service
providers were interviewed. Of these four were doctors, nine were ANMs, three were staff
nurses and one was a health visitor. Out of four doctors, 2 doctors completed a PG diploma in
Gynecology, one doctor had undergone MTP training and the other doctor had experience in
assisting abortions in a private hospital.
Service providers’ perceptions about abortion situation in India:
• Present abortion situation in India: Majority stressed on ignorance and social factors
as major reasons. Majority of the service providers said (11 out of 13) said that both
husband and wife are responsible for the current abortion situation in India.
• Abortion as spacing method: All service providers including doctors said that abortion
is not an appropriate spacing method. Less than half (8) of them said abortion can be
used as spacing method once or twice but not repeatedly. However, three of them said
abortion is a convenient method of family planning compared to other family planning
methods available.
• Preferred place for MTP services: Six out of 17 service providers said women do not
prefer to access MTP services at FRU/PHC level because they want To maintain
confidentiality about abortion. Five service providers said that MTP facilities are not
appropriate at PHC level.
• Service providers ’ perception about non-allopathic, non-medical and selfstyled local
medical practitioners providing abortion services: None of the service providers are in
favour of non-allopathic and non-medical practitioners offering abortion services.
Seven of them said abortion practice by them might lead to infection and risk to life as
they are not skilled to conduct abortion.

8

MTP training to ANM/nurse and TBA: Majority of the service providers (13 out of
17) said that ANM could be given training to provide MTP services, as she is close
AnxTx^CeSS'ble t0 the community- Only 4 service providers (two nurses and two
ANMs) said that only doctor should conduct abortion. Nine service providers said that
if doctors are experienced and qualified then their practice would not get affected by
training nurse/ANM/Dai for MTP services
• MTP training to self styled local abortionists: Majority of the service providers are
not in favour of non-allopathic practitioners to be trained in MTP services. Three
service providers said that safe motherhood services should be promoted but not
abortion services.
• Local abortion service providers in the village: Local abortion service providers are
present all over India even in villages. Some are qualified doctors, some are
gynecologists, and others are nurses and midwives. Besides these other non-health
persons could also practice abortion services. ANM VL and the dai in RPY village are
examples of such practitioners.

•

8. Discussion
Inadequacy of post abortion services in the public health systemiThe key finding of this
study is the extreme inadequacy of the content and quality of post abortion care in the public
health system. The study could record only 33 cases of abortion during a period of six months
(of these 27 were interviewed). This is not even six women in a month. The distribution of
cases shows that the majority are from the town in which the hospital is located.
k a mw r1 °f 27 w°me.n who had abortion in the government hospital, only three were visited
by ANM for post abortion care, follow up and advise. Only one out of nine women who had
abortion was visited at home within two weeks by the ANM. This is a critical time for the
woman physiologically and psychologically. There are many factors that lead to inadequacy
o post abortion care. Women’s low awareness and familiarity regarding the ANM is a major
factor. The ANM was not easily accessible since she was not available regularly. The other
reason could be the limited role of ANM in the area of abortion services. Though one of the
women in three village approached ANM with abdominal pain and bleeding, ANM refused
amw°
I37'"8 ShC d°eS nOt take UP SUch cases- Generally women do not approach the
ANM for abortion services because the ANM is associated mainly with antenatal services
Imw”65’ lmmanTltI0n and family planning services. The reasons for not approaching the
ANM are varied. Five of them could not reveal this information to the closest neighbours
(premarital sex or extra martial relation or rape). The distancing between the ANM and
Z"
m
n krt,°n iS Clear‘y S6en in the CaSe Of One woman whc did not Inform the
ANM even though she conceived after tubectomy.
S0 kiCtmOf/brrtiOn: More than half Of the WOmen seeki"g aborti°n services from the
public health facility are poor and underprivileged. They are illiterate or semiliterate daily
wage labourers Irom the scheduled castes and scheduled tribes. Cost of abortion was a major
the St H "T Of}mSe WOmen WhlIe Seeklng Services from the government hospital. However
gove nmeA hosenit^aThXCePt S'0 T0"16"’ 3,1 Paid m°ney t0 get abortion Services form the
government hospital. This unoificial payment is responsible for most women seeking services
fee toiheT "UrS1"g n°meS and h0Spitals- <1987)- Major chunk of the moneys in til form offee to the doctor About a quarter of this amount is used for medicines, bed charges payment
to the dai, etc. Women said that the amount they would have to pay for abortion in a private
hospital was nearly three times more. In one case the private doctor herself referred the
woman to the government hospital because the family could not pay her the fee. The women
^■ng abortion services at the government hospital were so poor that they had to borrow
even tins small sum and some had to mortgage or sell their assets such as goats. One woman
,h° !lves by making bajjis sold by her husband suffered severe financial crisis during the post
abortion days. This was their only livelihood.
g
P

9

The variable fee charged by the three doctors who provided abortion services revealed
interesting facts. The male doctor who lived in the hospital premises charged fee from all the
15 women who came to him but the average fee was Rs. 563.3. Compared to this, one of the
female doctors who attended only 8 women charged an average fee of Rs. 637.5. The second
female doctor who attended 4 women charged an average fee of Rs.875. She did not charge
any fee from two of the 4 women whose financial condition was very poor.
This is specially true for women in Andhra Pradesh where childbearing starts and ends
very early. According to NFHS age at marriage for women in rural areas is 14.5% and median
age at first cohabitation with husband is 14.9% years. The median age at first birth is 17.9%
for women aged between 20-49 years and 17.7% years for women aged between 25-49 years
of age in rural areas. Regarding the age at last birth 67.0% of women had their last birth by
age 30 and 86.0% by age 35. The median age at last birth for women aged between 40-49
years is 27.3%. Reproduction in AP begins at an early age and is highly concentrated in a
short span of about 10 years.
Health burden due to abortion and its complications: The inadequacy of post abortion care
from the public health system leads women to approach many different health facilities, in
some cases highly qualified or some caes non allopaths. Due to which women suffer with
financial, physical, psychological cost of post abortion management. In the case of one
woman, she approached healer for post abortion complication. In one case woman approached
the doctor who did the abortion with post abortion complication of excessive and continous
bleeding the doctor referred the woman to district hospital. At CHC and PHC level there is no
blood bank facility nearby to reach for the complication. With the onset of post abortion
complications woman lose her faith in the doctor who conducts abortion and approaches the
other service providers for better treatment. In one such case woman approached healer for the
post abortion complication. In search of better qualified doctor woman migrate to bigger cities
for treatment, most common complications woman suffer with are abdominal discomfort,
bleeding and weakness. All these complications arise due to lack of post abortion care.
Abortion leads to the anaemia in general.
Complications and interventions: In the case of one woman (GB) with no proper guidance
from public health system she underwent D&C three times to manage post abortion
complication. Women in search of proper satisfactory treatment, shift to different hospitals /
clinics where both health and wealth of woman and her family suffers.Some women after
abortion went to stay with mothers so that they can get some rest from household activity. In
one case women had ladoos made with coconut and ghee to gain the strength lost during
abortion. Most women had just bread and tea / milk which they generally take during fever.
Some women took one week rest and started their work.
Contraceptive services and information: Out of 27 women only six accepted family
planning after abortion. There are women who have enough number of children but did not
accepted contraception, this reflects the unmet need of contraceptives. There is a lack in
provider’s knowledge about post abortion care. Except one doctor all the service providers
interviewed including doctor, staff nurses, HV and ANM, none of them have received any
technical training regarding post abortion care and counseling. ANMs must be given technical
training separately for post abortion care and counseling. ANMs need to strengthen their
relationship with women.
Contraceptive options: What does the public health system offer women like GB or ZB who
already have completed their desired family size and do not want any more children yet do not
want to undergo sterilization? Both have four children - two boys and two girls. How can SF
who has seven children but cannot use oral pills or tubectomy because of high blood pressure
be helped? It appears that the family planning programme must focus more on IUD, inform
women about its advantages and create facilities for high quality IUD services. The hospital
provided services for women living within a radius of about 25 Kms. Only one person had
traveled about 100 kms from the capital city to this hospital because this was her mother’s
10

village. Further enquiry revealed that only - government hospitals in the district were

Cl* heX™S'° SOme “ ™S ““““ * Very

“vera8‘ Of ™

However the fact that 11 were older than 25 years reveals that there is a unmet gap in

vearr™sCiPJVetSerJIC^ ' 1,1656 “H' The aVerage age for the 27 w“ was 23.3

earlv to abort it Th’5 ha h°Se ^Omen who had an unwanted pregnancy tended to take action
for ah rt 6
lndlcates that more than three quarter of the induced abortion cases went
Ibortior Z'r the^Stf.lri,meSter- ComPared to this, only half of those who had a spontaneous
bort on had it in the first trimester. The need for post abortion care is equally important in
both type of women but the risk is higher among those who carry the pregnancy longer and so
the importance of post abortion care is much higher.
Why did women not receive pre and post abortion services from the ANM? Twenty four
of the 27 women who had abortion were not contacted by the ANM or any other service
provider before or immediately after abortion. One reason why women did not receive post
abortion care is the gap between the ANM and the women. ANM is the link between^he
health system and community but when community doesn’t know ANM how can community
access health services. Eight women of reproductive age did not know ANM at all Of the
ortheisWsmdrevCet;V 'hi^T
th6 ANK °ne W°man is a neighbor of the ANMnl^
I PUbJ>-C V631 SyStem WaS aware of only three of the abortions which took
place within the public hospital. This indicates the distance of the health system from
system The^NM’
“
Coordination between the hospital and the public health
system. The ANM s awareness of women’s reproductive health problems is dismally low
9. Suggestions and conclusions:
andheexnanededf
P6riph6ral uS6rViCeS Pr°Vider needs t0 be ^-examined, explored
and expanded. The most common problems that service providers face are in the area of
giving proper post abortion care in maintaining confidentiality of women who underwent
abortion and woman not expressing their problems freely to service providers are two major
problems faced during follow-up visits.
J

heakhsector6"688 amOng women and men availability of abortion services at public

’

Increase awareness among adolescents regarding the reproductive health and safe sex.
e access to contraceptives must be improved irrespective of marital status.
Couples must be sensitized towards family planning.
Sexual rights of single women must be considered.
Confidentiality issues must be considered in providing abortion services at public
health system.
H
Post aborti,on complication management facilities must be improved at the health
racihties where abortion services are provided.

ir

VJVV-

Executive Summary
Women, Work and Abortion Practices in Kancheepuram Distirct, Tamilnadu.
S.Anandhi

From the early 1980s, Tamilnadu has witnessed a sharp decline in fertility rate. This

fertility decline has taken place essentially through a strategy of family limitation,

especially among the younger age groups who have largely followed the terminal
methods such as abortions and sterilization. In this context, abortion is understood in

the existing literature singularly as related to upward mobility through family

limitation (at the micro level) and population control (at the macro level).
Against this backdrop, this study attempts to locate and recover other
connotations of abortion practices in the context of increasing number of rural
women, especially the young unmarried girls, being employed in the informal sector.

With unemployed men unable to perform the function of provider and given the

conditions of work for women in the informal sector, abortion has come to play roles
other than family limitation or population control. In the context of encountering the

sexual exploitation in the work place, abortion has become an alternative to losing the
job - thus, setting in opposition economic freedom and sexual freedom.
Simultaneously, with the increased spatial mobility of women, abortion also has

expanded working girls’ sexual choices. In other words, abortion at once constrains
and expands the domain of freedom for women. The study maps out these conflicting

roles of abortion in the lives of working girls and how they negotiate them through

culturally grounded reasoning.

I

vcy-v *?>'

Ethnographic Exploration of Abortion and Abortion Care Related
Community Needs in Velhe Block of Pune District
By
The Maharashtra Association of Anthropological Sciences (MAAS)
64/5, Anand Park, Aundh
Pune-411007
January 2003
Team members:
Dr. Sudhakar Morankar (PI)
Ms Bhupali Mhaskar (involved from beginning of project up to report writing)
Ms. Vidula Purohit (involved from data collection up to report writing)
Mr. Mrudul Patil (data collection up to completion of data collection)
Mr. Abhay Kudale (conceptualization up to pretesting of tools)
Executive Summary
1. Introduction:
Only 1 out of 15 doctors trained to perform abortions practice in rural India. Safe
abortion facilities are not yet available within reach of the rural people. Complications
from unsafe abortion kill at least 78,000 women every year. Of 11 million abortions in
India about 60% are induced abortions. This shows that there are some factors, which
hold back women in using contraceptive services and seeking safe abortion services
as a right. Women often resort to abortion with unwanted pregnancy either due to
failure of contraceptive method or non-utilization of contraceptive method. The
absence of appropriate quality of contraceptive services is one of the main causes of
abortion. Along with that other causes include, it is used as a method of birth spacing
and to limit family size. In several cases, the abortion was a desperate action on the
part of the woman, as the physical, economic and psychological stress of having an
unwanted child overrode any feelings of guilt and/or fear of complications they might
have. Their husbands were often unwilling to use contraception, leaving them to
suffer or cope alone.
Most abortion research until 1980s was hospital based with focus on aspects such as
socio-demographic characteristics of women, understanding reasons for abortion, type
of morbidity, cost of abortion care etc. The earlier research efforts were governed by a
perspective viewing MTP as one of the means for the state’s goal of population
control. The studies, which looked at abortion as study event, were all hospital based.
A closer look at the 17 community based studies indicate event most studied were
pregnancies related, prospective in nature were based in urban and rural areas, except
one all other recorded abortions were presumed to be non—legal. Generally rural based
studies seem to have recorded lower rate of abortion compared to those recorded in
urban-based studies.
In several cases of abortion seeking women, the approach of women towards abortion
was quite casual, some of them used to undergo abortion on a regular basis. Research
on abortion not focused its attention on the entire social, cultural, economical and
political context of the general community in which the abortion seeking behaviour
takes place. After Cairo conference since 1995 in Reproductive and Child Health
Programme along with target free approach (TFA), the need of Community Needs
Assessment (CNA) was emphasized. Following this when inclusion of abortion
services in RCH programme is considered then community needs assessment in true
sense becomes imperative.

I

Z-

The very focus of researchers on abortion seeking women tends to forget that they are
also the part of a community and abortion seeking behaviour like other health seeking
behaviors, occur in specific cultural, social, economic and political contexts. Ail
people in any given society do not have the same power to control their own
behaviour and the behaviour of others. In patriarchal set-up abortion-seeking
behaviour is varied, intricate and hidden but at the same time it is influenced by
gender, social structure and culture. To understand entire abortion scenario it is very
necessary to know community’s perceptions regarding abortion and abortion related
care needs. In addition, abortion literature shows not much evidence on general
community’s view on abortion. Therefore this qualitative study conducted in rural
Maharashtra tries to explore community’s perception about abortions in social,
cultural, economic and legal context

2. Objectives:
1) To understand cultural meanings of abortion in the community.
2) To understand the problem, perceptions and existing solutions for seeking
abortion in the community.
3) To understand socio-cultural factors influencing decision-making related to
abortion and abortion related care among women.
4) To find out the perceptions, practice and experience of the village level health
providers such as traditional dais, CHVs with regard to abortion and abortion
related care.

3. Locale of the study:
The study was conducted in 14 villages of Velhe taluka in Pune district of
Maharashtra covering about 10,000 populations. Pune district is one of the welldeveloped districts in Western Maharashtra. Velhe taluka is hilly and drought prone
area and relatively under developed. It is being regarded and listed as the most
backward taluka of Pune district by the Maharashtra state government. Velhe is a
taluka place situated at 65 km from Pune.
Strategy to reach community:
Going to villages in the evenings, when people had free time, consulting them about
how to proceed for data collection and seeking consent of community for undertaking
such study greatly helped us. During the phase of data collection researchers stayed in
villages and participated in their day-to-day chores on and off the farm. The
community shared their problems and views with the research staff. Interviews were
conducted considering respondents availability of time and at the place of his / her
choice. The researchers even participated in village festivals. Considering all these
issues it was really an ethnographic experience.

4. Methods:
To meet the objectives of the study following methods of data collection were
employed. Unstructured interviews were administered to 50 key informants (25 male
and 25 females) such as village assembly members, opinion makers; presidents of
women’s club, village health guides etc, Unstructured interviews were conducted to
identify the concepts of community members. Eight Focused Group discussions (4
male and 4 female) consisting adolescents, youths, and middle and old age group
were conducted for getting range of the concepts. Number of participants varied
between 8 to 13. To explore the depth of the concepts forty in depth interviews (20
males and 20 females) were conducted with community members. As abortion is a
sensitive topic to ensure objective response of all respondent we have used vignette
methodology.
Five vignettes were used to get community’s viewpoints on abortion.

3
Married woman who currently has one son and two daughters becomes
pregnant for the fourth time and does not want to bear a child.
<♦ Married woman having four daughters and for the fifth time she becomes
pregnant.
<♦ A young widow 23 years, of age becomes pregnant, in the village similar to
your village.
♦♦♦ A young woman of 25 years of age who is separated since two years and
becomes pregnant in the village similar to your village.
Vignette for out of wedlock
<♦ 16 year unmarried adolescent girl becomes pregnant in the village similar to
your village.
After presenting the vignette following questions were asked to explore community’s
perspectives, e.g.
• A young woman of 25 years is separated two years ago, becomes pregnant in
the village similar to your village. In this situation:
• What action she will take?

•

What action will her family undertake?

•

What will be the community’s response towards this situation?

•

Whether will she undergo abortion?

•

Where will she go for abortion?

• Financial and psychological problems she may face?
Process of decision-making: - at family and at community level
• Disclosure of pregnancy
• Decision of abortion
• Seeking information for place of abortion
• Place of abortion
• Accompanying person

5. Methodological and Ethical concerns:
As abortion is sensitive issue directly going to community and conducting interviews
was difficult. So to start the interview initially general health problems were
discussed, then eventually researchers started with the main topic of study i.e.
abortion. Actual experiences of the abortion seekers could not be reflected in the
study as the study is based on community perspective.
Regarding ethical issues, for each of the interview oral consent was sought after
explaining the project and its need. Confidentiality and anonymity of each interview
was maintained. While conducting interview after presenting vignettes the
respondents verbalized with actual cases and their own experiences. Original names
were replaced with dummy XYZ format when the interviews were transcribed,
translated and entered in to the computer.

6. Key findings:
Some of the key findings of the study are listed below. Implications of these findings
to providers and policy planners, which can help to improve the access to abortion
care.
6.1 Cultural meaning of abortion

Every action of an individual is a part of culture. Therefore abortion also becomes
very important event in the life of the woman with respect to culture. To understand
cultural meaning of abortion, it is necessary to know entire spectrum from fertility to
abortion. Major findings of this section are:
• Family and Community want a new couple to prove their fertility within one
or two years of the marriage.
• Fourth and fifth day after menstrual cycle are considered as most fertile days.
• Community does not differentiate “embryo” and “foetus” but called it as
“Garbh". Various periods are mentioned for starting of life (Jiva) in the
foetus. Until foetus starts moving in the uterus it is called a ball of flesh and
generally after 3rd month of pregnancy it is believed that “Jiva” started in the
foetus.
• People have concept of nutritious food to eat for good growth of the embryo.
• Concept of hot food is very important to the community and the community
has explained various causal relationships. Certain food items are identified as
“hot food” which is restricted to eat during pregnancy.
• Community has scientific, medical as well as traditional concepts regarding
infertility. Community also suggested the process for treatment of infertility
going to extreme for remarriage of a man.
• Temporary family planning methods scared the community leading them to
believe to infertility.
• Reasons for miscarriages are related from scientific, medical, social and
psychological and traditional beliefs too.
• Concepts related to miscarriage such as “hot food”, lifting heavy weight, poor
consumption of nutritious food are being utilized by the women who wants to
undergo abortion as their initial attempts for abortion.
• Concept to excessive bleeding is changing pads five times and more in a day.
• Culturally abortion is considered as “sin”. Those men and women'who do not
want child should use contraceptive. God proposes to conceive a child to
woman who has done good deed in past and this “god’s gift” be not rejected
through act of abortion which leads to commitment of “sin” and sin is
“punishable” and god executes punishment on the person in this very life.
• Community accepts certain conditioned type of abortion like woman having
more or only female children has allowed undergoing abortion. The woman
having only female children allowed undergoing for sex selective test and
abortion of female foetus due to social economic, and cultural burden on the
.family.
• “Izzat "(prestige) is of prime importance to the villagers. Out of wedlock
pregnancies and abortions in married as well as out of wedlock women are
considered as deviant behaviour. Any deviant behavior is considered as a
threat for the family as well as village “Izzat".
Generally all abortions are looked as sin (Pap), but community is having sympathetic
attitude towards the abortions in married women. All the respondents stated that no
married woman would go for abortion unless there are very severe reasons like only
female children or danger to her life. All the respondents stated that pregnancies
outside wedlock are not accepted in the community because in the community and in
Indian culture sexual relations are allowed only after marriage and within the wedlock
(Jila navara aasato ti batch garodar rahu shakate).

5

((Izzat,> is very important for the villagers. Abortion is a product of deviant behavior,
so abortion in the family is like threat for their family ‘‘Izzat ’' (Gharat koni padun
ciale tar gharyanache nak kapale jate). They are ready to do any thing to preserve
their “Izzat". Community disapproves out of wedlock pregnancies and subsequent
abortions because it is against cultural norms of the community.
6.2 Viewpoints about abortion and decision-making
Though abortions are culturally not accepted yet over six million abortions take place
each year in the country. This section tries to explore the disparity observed in
cultural understanding and actual occurrence of abortions within marriage and outside
wedlock. Major findings are:
• Community believes any abortion is unsafe. Foetus has been forcefully
uprooted from the uterus hence it causes problems to the women’s health.
• Community further stated that in some unavoidable cases abortions must be
done before third to fifth month of pregnancy. It is more painful as foetus
grows up after this period.
• Community strongly feels married woman should not go for abortion as: there
are “conceptive-temporary and permanent- available”. Community strongly
feels that people should adopt “tubectomy“ after desired number of children
and generally couple do not go for abortion, as contraceptive failure. They
strongly blame the couple those who go for abortion, however, community is
liberal towards the women who have more or only female children, they can
go for sex selective test and undergo abortion in case of female foetus.
• Pregnancy is prohibited to women who are separated/ divorced, widow and
unmarried. These women are blamed strongly for pregnancy and people have
negative attitude towards such women. They are sometimes vulnerable even to
get uprooted from the village due to family and village ^izzaf" (respect or
honor). Therefore, they have to keep their pregnancy and abortion very secret.
They visit only private providers located far away and pay more to maintain
the secrecy. To satisfy sexual urge of such women community suggested that:
Separated women should get divorce and get married to a person whom she
likes.
i.
Divorced women should get married whom they like.
ii.
Widow marriage is also suggested.
iii.
Unmarried girls should be married at an appropriate age.
Cultures are never static; other human groups around them usually influence them and
they are in the constant process of adoption and change. This quotation can be related
to our study area. Earlier pregnancies outside marriage and abortion were strongly
stigmatized and normally punishments for such deviant behaviour were desertion or
force her to commit suicide. But now community reported that secret abortion has
accepted because rural community has transformed from strong “ we” attitude
towards more individualistic attitude (aajkal tatakhali sagale chalate aapan kashala
bola aaj tyanchyavar vel aali udya aapalyavaar aali tar).
Matrix below shows the viewpoints of community towards abortion within marriage
and outside marriage at a glance. This matrix helps in understanding the community’s
viewpoints from their perceptions.

Community’s Understanding About Abortion
Vignettes

Variables

Married
Married
woman
woman
having one
having
son
and
four
two
daughters
daughters
Blame
Pregnancy

for

Widow

Separated

Unwed

Female
foetus

Yes

Yes

Yes

k

■kkkk

•k -k -k ■k "k

Yes
Sympathy

Yes
Strong
Stigma

Yes
Strong stigma

Yes
Stigma
Little
sympathy

Mother-inlaw/
Husband

Self /Parents

Self

Self/Parents

Private Setup

Private
Setup

Private
Setup

?

No

No

No

No

No

Yes

Yes

Yes

Mother-inlaw

Mother-inlaw

Parents/sister/ Alone/partner/
Aunt/Partner Friend

No

“Izzat”________
Community’s
approval
for
abortion
Apathy

Final decision
maker
for
abortion

Mother-inlaw/
Husband

Providers
Private
Govt,
or
and/or
private
Govt.
Setup
Setup

Consideration
of
Economic
affordability for Yes
abortion
Secrecy
maintained
Accompanying
person

Parents/Aunt/
Partner

Note “****♦” Indicates maximum threat to 'Izzat"” and
indicates no threat to
“"Izzat””) ? = For sex determination no economic consideration, but for abortion
government facilities may be used.
6.3 Village Level Providers Perspective
To explore community’s perceptions about abortion and abortion related care it is
necessary to take into account the perceptions of the village level health functionaries.
Village level health functionaries, included are basically village level health care
providers; six dais, one male Community Health Volunteer (CHV), one private
practitioner (Ayurveda) and two Auxiliary Nurse Midwives (ANMs) were
interviewed as key informants in 6 study villages. Major findings of this section are:
44* * ***55

Community based and village level health workers are not involved in
conducting any illegal abortion using traditional method, as modern
services are available within lOOkms from study area.
• Providers corroborated the community’s perception for married and
out of wedlock pregnancies and abortions.
• Post abortion complications mentioned by providers are similar as
community reported. Community as well as community based
providers suggested to provide post abortion care and miscarriage
services to be created / supported at village level.
The traditional methods for abortion now are not in practice in the study area. The
nearest available medical facilities for abortion and abortion care are used rarely. In
the sensitive issue like abortion, secrecy is of prime importance and to maintain it far
away places such as Pune, Satara, Shirwal are chosen for abortion. Village level
health care providers have very little knowledge about MTP Act; the providers know
only conditions permitted for abortion. Dais know nothing about the MTP Act.
Thus the study shows that village level health care providers are having almost no role
in providing abortion services and abortion care in the study area.

•

7. Implications:
7.1 Implications for Information, education, and communication.
Exploiting appropriately community’s various concepts regarding cultural meaning of
abortion, viewpoints about abortion and provider’s viewpoints, following research
and IEC activities are suggested.
I. Research in IEC: Despite knowing “temporary and permanent”
contraceptive methods still abortions are conducted. Why this happens?
Research questions:
Why there is gap in knowledge and practice of family planning methods?
What is the specific knowledge regarding family planning methods?
II. IEC Activities:
a. Provide scientific knowledge on continuous basis about concepts of
fertility, care during pregnancy, embryo and foetus, importance of
various types of food, infertility and disseminate MTP act to
community as well as to community-based providers.
b. Develop IEC material respecting of community’s views and
concepts including outlooks towards the “temporary and
permanent” family planning methods, Signs of difficult
pregnancies, Importance of early visits for ANC’s, The MTP Act,
risks in abortions after 20 weeks and risks in undergoing abortion
in unauthorized set up. What are post abortion complications? And
How to handle post abortion complications?
c. Educate people about “temporary and permanent” contraceptives.
(How to use it, Chances of failure, their side effects etc.)
d. As community stigmatizes out of wedlock pregnancies, there is an
urgent need to conduct IEC activities on family life education/ sex
education for adolescents and youth.
7.2 Further research to understand details with regard to abortion
• Conduct research on concept of hot foods and various activities restricted
during pregnancy and its relationship with miscarriage/ spontaneous abortion.
Women who want to undergo abortion use these methods/ activities. What is
the utility of these methods for abortion?

Registration of miscarriages can be incorporated in RCH management
information system, which will be useful to estimate the magnitude and to
provide public health services.
• An intervention research can be carried out to prevent sex -determined
abortions. How to prevent sex determined abortions? and how to change the
current perceptions of the community regarding sex determined abortions?
• Community allows sex selection test and female foetus abortion for women
who have more or only daughters. Research can be conducted on such couples
with only daughters to study the economic, social, cultural, psychological
burden on the couple, family and girl themselves.
• Understand more about the individual, family and village “Izzat” (respect)
related to abortion by married and out of wedlock women. This will help to
understand the patterns of “Izzat" and its relationship with the utilization of
abortion services. E.g. To preserve family as well as individual “Izzat" out of
wed lock abortions are conducted at far away health care service centers and it
is also difficult for such vulnerable women to utilize nearby abortion care
services for post abortion complications.'
• Involve community in research how community becomes more responsive
towards improving status of out of wedlock women and reduce the drudgery
they currently face.
7.3 Need for post-abortion care services
Community stated that in their area magnitude of abortion is about 10%. Most of the
abortion seekers choose far away places for abortion. Community reported that post
abortion complications are not seen very frequently. Only one amongst several will
have post abortion complications. Instead of special abortion care services community
prefer to have general health care services at village level in which abortion care
services are included. Village level providers can be equipped with these services.

•

* * * jfc * +

I

Abortions in Rural Community Near Urban Areas:

Experience of Married Women

Anjali Radkar

Executive summary

‘Every pregnancy should be intended’ is the vision of International Conference on

Population and Development. However, there happen to be a few unintended
pregnancies and a few intended pregnancies with unwanted outcome. These situations

call for induced abortions all over.

Abortion, though most commonly performed gynaecological procedure, has a social

stigma. It is one of the silent issues in women’s reproductive life. In the absence of
legal sanction, abortions would be performed in unsafe and unhygienic conditions

causing abortion related morbidity and in some cases even mortality. Thus taking into
consideration the health hazards associated with abortion, it has been made legal in

India in 1972 on certain grounds. Induced abortions then referred to as Medical
Termination of Pregnancy (MTP) when conducted legally.

The reason for abortion regarding the contraceptive failure mentioned in the act
provides abortion almost on demand to all married women. It is generally observed

that women have unfavourable attitude towards abortion therefore in spite of it has
been legalized in India for past thirty years now, they tend to hide it. Thus hiding the
information about abortion is one of the major hindrances to get the knowledge about
the extent of the foetal wastage in general and induced abortions in particular. Efforts

have been made in large sample fertility surveys to collect these data, which have not

been so successful. There are some clinic based studies that provide some information
about abortions, which also is incomplete in a sense, sample is selective and very
little information about the processes and patterns of abortion is available from these

data. There is a need for field-based studies that can shed light on hidden issues of
abortion in general.

An effort has been made here to get as much information about abortions from
currently married women residing in the villages on urban fringe to add to the
existing knowledge of abortion. The major objective of this study is to understand the

whole process of abortion, from thought to action and thereafter in the light of role of
women in decision making of abortion, role and support of the family, detailed

information about the reasons for abortion, extent of sex determination tests and
female foeticide, choice of provider and quality of care, contraceptive use before and
after abortion, abortion related trauma, perceptions of various issues of abortion of

men, adolescent girls and boys, health functionaries and village functionaries.

The study is conducted in two purposively selected villages namely Bhugaon and
Bhukum about 15 and 20 Kans, away from Pune city. Both the villages are connected

to the city by bus as well as by private jeeps and rickshaws. Villages on the urban
fringe are selected to study the pattern of abortions among women who have rural
living but have exposure to urban thought and infrastructure. Women there have

access to safe abortion services in urban area in addition to rural health facilities.

Women, who have undergone induced abortion, are identified after conducting

household survey. Then in-depth interviews of these women are conducted to get
whatever they have to report about their abortion experience. In-depth interviews of

village functionaries and abortion providers are also conducted to get a clear idea of
abortion situation in the villages. Focus group discussions of women who have not
undergone induced abortions, men in the village and adolescent unmarried girls and

boys are arranged to get the complete picture.
In the two villages, the data are collected form 940 households, 556 from Bhugaon

and 384 from Bhukum. Among these houses, 933 currently married women (562
2

z
from Bhugaon and 371 from Bhukum) in reproductive ages are interviewed. It is
observed that per interviewed woman there were 2.79 pregnancies, 2.52 live births,
0.14 spontaneous abortions, 0.08 induced abortions and 0.05 stillbirths. Thus foetal

wastage per woman was 0.27.

Among 933 currently married women in reproductive ages, 65 women experienced
70 abortions. Four women experienced repeat abortions. Three of them sought the
abortion twice and one has sought it thrice. Repeat abortions of two women are

conducted because medically advised. Other two women used the abortion as a

spacing method of contraception.

Age of women at the time of seeking abortion shows inverted U pattern as seen in
many countries. Abortions are sought more in younger ages. Abortions seekers are
more educated compared to other surveyed women. About 60 percent of them have

occupations other than housework. Standard of living of most of these women is

either ‘medium’ or ‘high’. Thus a typical abortion seeker here is a young, more

educated woman having some occupation and better living standards.

Reason to resort to abortion is a complex phenomenon. Thus it is difficult to put it

under just one category. Still the efforts are made to sort to it out and come to the
most important one. Very few women use family planning methods for spacing and

those who use, also use it in an ineffective way or irregularly. The reflection of this
fact is seen in reasons of abortion. The reasons for abortion reported in this study are
mainly spacing between the children - in 17 cases or limiting family size - in 33

cases. Sex detection is getting common and women resort to abortion if the foetus is
female. In this study eight such abortions are identified. In the remaining cases
abortions were medically advised or it was difficult for women to continue the

pregnancy. In three cases women went for it because of earlier mentally retarded or
invalid children and in one case husband of the woman wanted to get married again.

3

3 •
Sex detection was theoretically not accepted but practically women felt it necessary
because of deep-rooted preference for sons in the society. When number of daughters
is increasing without having any son, sex detection and abortion of female was
justified by most of them. Son preference exists in all cross sections of the society and
among both men and women. Therefore sex detection followed by abortion of female

foetus has got social sanction in the society in particular cases, though in general

attitude of both men and women is unfavourable for it. Considering the scale of these
practices only 8 women reported abortion of female foetus though more mentioned to

have undergone the test.

Women in the rural areas near the city have more exposure to all urban infrastructure

than their typically rural counterparts. They have more access to information and
health care. They are much more exposed to the knowledge regarding importance of
spacing between the children and also of the small family. In this study most of the

abortions are conducted for these reasons. Thus the role of women in decisionmaking of abortion is more visible here, probably because woman suffers the most by

carrying an unwanted pregnancy and bringing up then unwanted child. Husband and

wife took most of these abortion decisions together. No secrecy about the pregnancy
was maintained in most of the cases. Women also reported that they enjoyed a

support of the family especially of mother-in-law. Her support is reported crucial as
she accompanies the woman for abortion or takes care of the house and earlier

children when the woman is way for abortion and helps her get the necessary rest

after abortion.

In this study two thirds of the abortion are first trimester abortions and remaining one

third are second trimester. Mean duration of gestation for this sample is 12.4 weeks.

Seeking abortion from the doctor is a step-by-step procedure carried out in all the
abortions. Women initially try something on their own if they get an unwanted
pregnancy. If that fails, they seek somebody’s advice to get spontaneous abortion and

4

k
if that does not work out then they go to the doctor for safe abortion. Four women

have reported their trials to induce abortion at home, by eating the stuff that is

considered unfavourable to continue pregnancy. When unsuccessful, all of them went

to the doctor for abortion. Thus all the interviewed women who have sought abortion
had safe abortions. In these 70 cases, no woman had visited a traditional healer or

gone for unsafe abortion. Sample villages being near urban areas, women had a wide
choice as regards the place of abortion. In this study 70 abortions are conducted in 43

different centres. Out of these 32 centres are private hospitals or clinics and 11 are

public health facilities like PHC, corporation hospital, civil hospital or a trust hospital
where the procedures are conducted at minimal cost.

All respondents consider abortion as a difficult procedure and if not done properly
can cause harm to women. It is seen generally that women prefer private health

facilities over public for abortion. Most of them feel that quality of care they receive
in private is better and time spent is much less. Considering the cost of visits to public

hospitals and cost of medicines to be purchased, they feel the difference in the cost is
marginal. The range of the abortion cost reported in this study is from Rs. 50 to Rs.
10000, with most frequently reported cost as Rs. 3000. In case of all second trimester

abortions the costs were sizeably more than the first trimester ones. Thus abortion is a
costly affair in general.

If the women have to seek sterilization after abortion, they go to the government
hospitals or sometimes somebody takes them to government hospital as a ‘case’ of
sterilization.

Consent of husband for abortion is reported to be required universally. Most of them

did not know that husband’s signature is not required for seeking abortion. But even
in case of abortions in private hospitals women reported that their husbands signed.

5

This study includes abortions of only currently married women and it has also come

out that more than two-thirds of the abortions are sought either for spacing between
the children or for limiting the family. Probably because of these reasons these
women look at contraception after abortion more positively. In 24 cases terminal

methods are accepted and 14 women went for some spacing method. Only in two

cases compulsion to accept contraception is mentioned. Provider in one case was
private hospital and in the other, low cost trust hospital. In both these cases the reason

for abortion was to limit the family.

More than two thirds of the women were not aware of possible complications during

and after abortion. All the abortions in this study are conducted in the hospital and

that too more in private hospitals. Complications are minimal, though a few have
reported trauma during the procedure either because of the drug allergy or while

removing the already existing Cu-T. Fifty-six women did not report any health

problem after abortion whereas 12 reported problems like heavy bleeding, pain in
waist and weakness. Two other faced severe problems. It is observed that those who

had some trauma during or after abortion, only report negatively about quality of care

they received, especially in terms of competence and behaviour of the doctor and the
staff and cleanliness and other facilities in the hospital. Those who had no problems

then, tend to forget the experience or may be not willing to go through the process
mentally.

Ideal arrangements for abortion according to almost all women include, cleaner

hospital and availability of water. They also preferred presence of lady doctor and

medicine in the hospital. Majority also suggested about the arrangement for food for
patients and for their relatives nearby.

Reactions of the elder family members were never reported as strong reactions

because in most of the cases mother-in-law knew about it. She has reported to protect
the woman from stronger reactions of father-in-law in some cases. However in many

6

cases elder members were reported worried for the woman, for abortion associated
health problems. Abortion to limit the family is not approved by few elders who had

larger family norm.

It is difficult to capture the feelings of women after abortion, as it is a common
experience that women do not approve of abortion but still go for it many a times
after taking the decision on practical level. Thus less than half report that they ‘felt

bad’ after abortion and less than one third report ‘no feelings’. About one fifth
reported the relief after abortion. Remaining women had a feeling of grief and guilt.

They felt it is a ‘killing’. Women having problems during pregnancy felt that ‘it is all

over’.

Women are not aware of the legalities of abortion. Almost all of them do not know
the permitted reasons and permitted duration of gestation. They only know that sex
detection and abortion of female foetus is not allowed and they can be punished if

they do so. They also know that if baby is malformed then abortion can be performed.

Response to the allowed duration was based on their pregnancy and childbirth
experience like 4 months or 5 months. Nobody could give what the law states.

Abortion carries negative connotations so village functionaries deny the existence of
induced abortions in the village, particularly abortions of female foetus. Though they

are keen on provision of health care to women.

Health functionaries agree to the fact that if MTP is followed by sterilization then

only women prefer to public health facilities otherwise the trend is to seek the

abortion in private.

Men in the village have more correct knowledge about abortion law than the women

and have right perception about the severity of procedure, if not conducted safe. Thus

7

i

7men universally approve of private health facilities over the public especially for
abortion, in spite of the costs involved.

Majority of adolescent girls and boys know that abortion is legal and female foeticide
is legally not permitted. Role of media is thus seen powerful here because all of them
mentioned that they have heard about it on television or read it in newspaper.
Knowledge of adolescent boys is seen to be more precise than adolescent girls on
various issues about abortions and reproductive health. Knowledge is a first step

towards practice so there is hope that new generation will not go for unsafe abortions
and female foeticides.

Women go for safe abortion if facilities are available, thus the facilities for abortion
need to be increased to curb unsafe and illegal abortions. To get the registration for
performing abortions minimum standards in terms of equipment and manpower of the
clinic or hospital should be assessed more critically so the quality of care while doing
the procedure will be enhanced. A point should be made that women can be admitted

under observation of the doctor in the hospital at least for few hours after the
procedure. That space has to be available in the hospital. Similarly the costs of the
abortion procedure and medicines should be lowered so that cost would not be the

constraint to terminate an unwanted pregnancy. Ideal arrangement for abortion

facilities includes presence of lady doctor, availability of medicines in the hospital,

availability of water and clean atmosphere. It is evident from the study that unmet
need for contraception is all over, even in the villages near the city, as women use
abortion like a spacing method. Thus use of spacing methods need to be promoted.
Strong preference for sons is reflected by widespread use of prenatal sex detection
techniques and female foeticides. Thus conscious efforts need to be made to enhance

the status of women and reduce gender inequalities taking help of all forms of media
and education material. Media definitely plays role in formulating attitudes. After
2001 Census media spread the message that sex ratio is declining and sex
determination followed by female foeticide is a punishable offence and both doctor

8

and patient are penalized when caught. Awareness need to be created among doctors
community as to not to conduct sex determination tests at all and also not to reveal

the sex of the foetus when women go for a ultrasound test as an antenatal check-up.
Awareness should be created among women that they should not go for abortion after

20 weeks of gestation as mentioned in the act, because those terminations cause

severe health problems for them during and after abortion. Women in general should
be made more aware of the legalities of abortion so they will not hesitate to go for
safe abortion, if required.

9

!

Role of Informal Providers in Abortion
A Case Study of two Village of Jind District
In Haryana

- Sandhya Barge, Wajahat Ullah Khan, Yamini Venkatachalam

Background
Despite a liberal abortion law in India (the Medical Termination of Pregnancy Act of 1971),
every year an estimated 5-6 million induced abortions take place in India, of which only 10
percent are conducted under safe conditions. Most of the abortions, especially in the rural
areas, are conducted illegally by untrained personal under unhygienic and unsafe condition.
Existing research shows that even where the services are available they are underutilised,
mainly due to lack of knowledge in the community regarding the legality and availability of
abortion services, cultural sensitivity, uncompassionate attitude of the providers, hesitation to
avail services from male providers and lack of or inadequate post abortion care. Thus safe
abortions are still inaccessible for a large proportion of women, especially those in the rural
areas. Research shows that among abortion providers, private doctors, informal providers like
dais, literate diploma or degree (other than MBBS) holders, herbalists, even illiterate persons
providing abortion far outnumber the public sector abortion service providers (ICMR, 1989,
Chabbra and Nuna, 1994, CORT 1997). To understand why and how these informal
providers are accessed for abortion services HEALTH WATCH commissioned Society for
Operations Research and Training, to carry out a qualitative assessment of informal providers
in the district of Jind, Haryana. The study aimed to explore the generic pathway that a woman
takes to select an informal provider, when she has a missed menstrual period and thinks that
she is pregnant; and to understand the abortion related services provided by the informal
providers and their relationship with the formal health system and the community.

Study Area and Methodouogy
The study was carried out during August-October 2002, in two PHO villages of Jind district
in Haryana. As mentioned above, the study was entirely qualitative. Focus group discussions
(FGDs) and in-depth interviews were the techniques used for data collection. A detailed
guideline was prepared and translated into local language.
The present study coincided with another SORT study—a quantitative survey of
abortion facilities—in the same study area. Thus SORT already had a list of formal and
informal providers of abortion related services. From this list, another list of informal
providers who reportedly treat delayed menstruation was prepared.

i

The two PHC villages were selected from two different blocks for this study based on
criteria, like number of informal
Coverage
providers available in the village and
No.
providing services for delayed
Community
menstruationi to women, caste
FGDs with the women
composition
and
geographical
2
FGDs with the men
Interview
with
the
women
who
had
experience
location of the village. To maintain
4
of miscarriage and induced abortion
the
identity
of the
village
Providers
confidential, the same has been
7
In-depth interview
referred to as village A and village B
Group discussion with the ANMs
1
in this paper. Village A was selected
1
Group discussion with the Informal providers
from Safidon block and village B
from Uchana block of Jind district.
As per the study design, in each village at least two FGDs were to be conducted with
women and one with men. Finally, seven were conducted, five with women and two with
men. In addition to the FGD with men and women, four women who had ever experienced
abortion or miscarriages were interviewed, zten in-depth interviews were to be conducted
with the informal providers in villages, but only seven could be successfully completed.
Group discussions, one each with the informal providers in the village B and with the ANMs
in village A were also conducted. Frequent visits were made to these villages for rapport
building with the informal providers and the purpose of study was discussed. One of the
informal providers was taken into confidence and explained in detail about the study, which
included confidentiality of the respondents, findings and purpose of the study. He was further
requested to gather at least 6-7 informal providers of the village at a single point for the
purpose of group discussion.
The operational definition of informal providers in the present study is: those (mostly
males) who are practising in the villages and providing treatment for the health problems of
the community, and are referred to as “village doctors” (gaon ka doctor) by the villagers.
They do not have not formal training or qualification in any system of medicine. The
villagers are aware that these “doctors” are not qualified but they still call them “village
doctors”. Besides these “doctors”, traditional birth attendants in the village, commonly
known as dai, have also been considered as informal providers. While the term ‘informal
providers’ includes both, it has been used interchangeably with the term ‘village doctors’.

Irrespective of the methodology used, the discussion on abortion was always initiated
cautiously. First by, asking the respondents what women generally do when they miss their
menstrual cycle, how is such a situation handled, what kind of treatment is sought for
miscarriages etc, and then getting into details about abortion.
A total of 35 married women who had experienced at least one pregnancy participated
in the five female FGDs and 14 men participated in the two male FGDs. Majority (80
percent) of the women were not older than 30 years, while a little less than two-thirds of the
men were in the same age group. The mean age of the male and female participants was 28.3
and 26.6 years respectively. Among the males, all except three were literate. All women
participants from village A were literate, while half of their counterparts in village B were
illiterate.

2

Sources of Health Care and Treatment Seeking in the Community
The discussions revealed that for common, or what the community perceived as minor health
problems, like cold, cough, fever, headache, villagers generally approach the village doctors
for treatment. They approach the formal providers in the city/town, only if the problems
persists or worsens. In which case the villagers generally go to Safidon or Jind. In their
words,

For small things like fever, cold, cough people take medicines from these doctors
sitting in the villages, or from what you might call jhola chhap (quacks) doctors only.
But ifone does not get cured here, only then one has to go to Safidon or Jind.
When we do not get relief (from the medicines given by the village practitioners) and
feel that we cannot even getup from the bed, then we go to Jind.
Safidon is at a distance of 10 km from village A and Jind, 20 km away from village B.

The services of informal providers are utilized mainly because they are the only easily
accessible source of health care for the villagers; no other qualified doctor is available in the
village. Some women also mentioned that people who are poor have to prioritize from where
they should seek treatment. Since expenses incurred would be higher if they go to Safidon or
Jind to seek health services, they prefer not to spend much on “minor problems” like fever,
cold or cough and hence they approach the informal providers in the village for medicines.

The PHCs in both villages are not a preferred source of health care. Villagers
complain about the non-availability of PHC doctors and they do not have any faith in the
quality of treatment provided by these public health facilities. Though both villages included
in the study are PHC villages, most of the participants complained about the non-availability
of the doctor at the PHCs in both villages. As a male participant from village B said during
FGD,
There is neither medicine nor doctor. I came to know that there is a MBBS doctor
posted at the PHC, but I never saw him till date.
Women from village B added:

Why should we go there? What we will do? We do not get cured by the medicine,
which they provide to us.
They provide the same kind of tablets for all types ofproblems.
It does not matter to them whether it is a wound or some itching; they provide the
same old medicine for all kinds ofproblems.

For Women’s Reproductive Health Problems
Most men were ignorant about reproductive health problems of women, while women
mentioned white discharge, watery discharge, excessive bleeding, frequent menstruation,
pain during menstruation, vaginal itching, stomach-ache, burning, blood during urination,
backache and bleeding during the pregnancy as reproductive problems that women may
suffer from. For the treatment of women’s reproductive health problems, most of the male as
well as the female participants mentioned that women mostly go to Safidon or Jind, because

3

there are no qualified doctors available in the villages to treat women’s reproductive health
problems. According to the participants, doctors in Safidon and Jind are “qualified”, “have
degrees”, “have experience and good facilities”, and most importantly, “women doctors are
also available” at these places.
For Abortion Services
Almost all the men and women were aware about the providers (places and persons) who
give abortion services. Most of them even mentioned the names of qualified doctors in the
private hospitals in Safidon and Jind, who provide abortion services. Interestingly, all
participants knew the names of women doctors who provide abortion services at these places.

Both men and women participants reported that abortion services are mostly sought
from the formal providers in Safidon and Jind, because the services are good, a greater
number of providers are available to choose from and these providers have the necessary
qualification and experience.
While private hospitals and clinics generally charge Rs. 1000 to Rs. 5000, public
clinics/hospitals charge up to Rs. 500 for abortion services. However, some of the women in
the group discussion also mentioned that the cost of abortion services depended on the
gestation period; longer the duration, higher is the charge.

Some of the participants also reported a sharp increase in the cost of abortion services
due to the ban on sex selective abortion. Most of the participants also believed that abortion is
presently banned.

Knowledge and Attitudes towards Abortion
Regarding awareness of participants
about the legal status of abortion, it
was surprising to find that most of
the participants thought abortion is
banned due to the decline in the
female sex ratio. They said,
It is banned now.
It is banned because girls
are getting lesser.

Anganwadi worker told us
that abortion is banned now
because girls are lesser (in
number) and boys are more.

Attitudes towards abortion
"It is a great sin. ”
"It (pregnancy) is God's gift (so should not be destroyed). ’’

"It is a wrong thing to do. It also harms one’s body. ’’
"It is very bad, having abortion half way (in the
pregnancy). ”

"It is better to use Copper T, Mala D or get operated (than
have abortion). ”
"It is wrong to abort 1-2 month oldfoetus. Ifsomebody does
not want a child then they should tty to prevent pregnancy. ”

"Ifyou examine the sex of the foetus and decide to abort the
female foetus then it is improper. ’’
- Men and Women

4

They seemed to equate
abortion
with sex selective
abortion. Hence due to the
enforcement of ban on sex
selective abortions the group
perceived that abortion per se is
banned. Generally their attitude
towards
abortion
was
not
favourable. All the participants
except a few were in favour of
abortion under certain conditions

When is abortion justified?
“If one miscarries then one has to go (for abortion), in that
situation it is compulsion ’’
“If somebody has 4-5 children and do not want more
children. "

“If the last child is too young. ”
“Ifsomebody has only girls and do not have boy. "
“If doctor advises (due to health problems of the woman).''
“Ifsomething is wrong with the pregnancy. ”
“If a woman is going to die then one has to abort it. ”

“If the child in the womb is weak and it can die inside then it
is ok. ”
- Men and Women

Treatment Seeking for Delayed Periods, Miscarriage and Abortion
Available research on abortion shows that women seek abortion from multiple sources.
(Chabbra and Nuna, 1994, ICMR 1989, CORT, 1998). Women, especially those in the rural
areas, first try out home remedies - indigenous methods like herbal concoctions, procuring
over the counter drugs from chemists, inserting objects etc to induced abortion (CORT,
1998). The advice and assistance of dais, health workers and other informal providers is
sought, either after trying out home-remedies, or directly. Formal providers are generally
approached if these home-based remedies and treatment by informal providers fail to induce
abortion or if women experience abortion complications (CORT, 1998). However, this is not
always the rule as there are also women who directly approach formal providers. The present
study also found a similar pathway to abortion services. As mentioned in the methodology,
before moving on to a discussion on abortion seeking, in all FGDs, the participants were first
asked about the sources of treatment for delayed menstruation in their villages.
Delayed Menstruation

Women in the villages seek treatment for delayed menstruation from multiple sources. Most
of them first try out homemade preparations, called kadha (concoction) if it does not work
then they go to the service provider, who in most cases is an informal provider. It is a popular
belief in the community (as well as the informal providers as discussed in the later section)
that intake of hot foods, i.e., foods that are believed to generate heat in the body, help in
resuming the missed period. According to the female participants:

Women take something garam (hot) like a kadha and if it does not help, then one has
to go to the doctor. These are the only treatments that women try by themselves.
In the male group discussion, some men also mentioned home-based treatment for
delayed menstruation like drinking kadha by women,
Yes, there is something they used to give like kadha of hot things (garam-masala).

5

In order to understand what kind of
kadhas do women usually prepare and their
perceived effectiveness, participants were
asked to describe these in detail. The
kadhas usually consist of dry fruits, tea,
ginger, jaggery, garam masala, milk or
water, seeds of roots like carrots and
radish, etc. These ingredients are said to be
‘hot’, i.e., generate heat in the body and has
to be taken hot in the form of a decoction
two to three times a day. The recipes for
these concoctions are already known to
many women through older women in the
family or among the relatives. Most of the
men did not know about the ingredients of
the kadhas, they said:

Commonly used ingredients of ‘k adhas’ for
resuming menstruation
IVomen are given some hot preparations like,
currants boiled in milk or tea.

Make very strong tea by adding a lot of tealeaves
and drink it hot.

Add 2-3 dry dates (chuware), 2-3 almonds, 5-6
currants to two cups of water and boil them. If it
does not work then we have to go to the doctor.
Just take some thyme (ajwain), dry dates
(chuware), jaggery and boil them in water andjust
drink it.
Take a teaspoon of pure ghee, 4 to 5 diy dates
(chuware), add some jaggery, thyme (ajwain), boil
them together and drink.

Add ginger and dry dates to one cup of water and
then prepare it like tea. After it is boiled well, drink
the kadha twice of thrice, then the menstruation
will start.

Our parents or household (female)
members give them some kadhas.
So how are we supposed to know
what these are made of?

- Women in Grouo Discussions

They (women) have their own
formulas, like jaggery, cuminseed, this and that. We do not know anything about it

According to the respondents, these concoctions work only if menstruation is delayed
by 10 to 15 days, or not more than 20 days, after which one has to approach a doctor for
abortion. In the words of a few women:
It works only if 10 or 15 days have passed, it would not work more than that.

It works only if 10 days passed it would not work ifsomeone is 4 months pregnant
It works, if it is 15 or 20 days delayed after that one has to go for abortion.

There was a difference of opinion among women regarding availability of treatment
for delayed menstruation. Some women in both villages claimed that there was no treatment
available in their village for delayed menstruation. In contrast others said that it could be
obtained from the village doctor (informal provider) and from the chemist shops in the
villages, which are said to stock all kinds of medicines. In their opinion the informal
providers in the village are competent to handle such cases.

There are many doctors in the village, you can get 3 or 4 doctors at every mohalla
and they provide the treatment for delayed menses, (a female participant of village A)
Every thing is available here. There is a doctor in the village (mentioned the name of
doctor). There is a medical store in the village and all medicines are available there.
(a female participant from village A)

6

Women seek treatment for delayed menstruation from village doctors and if the
problem is serious like the menstruation does not resume or there is excessive bleeding only
then they go to the city to the formal providers. According to a woman of village B

First we go to the village provider. If we get well fine otherwise we have to go to Jind.
If the problem is major, we go to Mandi (Safidon), if it is minor, we show it to the
doctor here itself, (a female participant from village B)
It is not very uncommon for women to send their husbands to get medicines from the
doctors in the village. Again only if there is some major problem after taking the medicines
prescribed by the village doctors, they go to formal providers in Safidon. As one of the
women described:

They (women) send a male person (husband) to the doctor and he brings medicines
from the doctor. If the problem is more serious then they go to the Mandi (Safidon)
and ifproblem is not serious then they get treated in the village.

Services provided by village practitioners for delayed menstruation
Regarding the type of services provided by the informal providers in the village for the
treatment of delayed menstruation, once again the response was “doctors provide garam
dawa (hot medicines) ”. Probing revealed that village practitioners provide tablets and or
injections. All participants could describe the drugs only as “hot medicines”, i.e., medicines
meant to generate heat in the body so that women would start menstruating again. At the
same time it was also acknowledged, though not explicitly, that this also helps in inducing
abortion, if the cause of the delayed period happened to be pregnancy.

Almost all village doctors (informal), as reported by the women, do not conduct any
kind of test or check-ups to rule out pregnancy as the cause for the missed period. They only
prescribe or administer medicines and injections without any tests. According to the
participants, tests and check ups are done mostly by the formal providers in the cities:

No check up is done here (in the village) it is only in the private hospital. Lady doctor
does the checkups.
No check-up is done by the village doctor, check up is done by the nurse in the
hospital.
There are two likely reasons for this: first, women complain only of delayed
menstruation, even if they might have suspected pregnancy, so they have to be treated only
for delayed menstruation without carrying out tests to confirm conception. Second, more
important, these informal providers are well aware that they are not authorised to conduct
abortion. They do not conduct any tests to confirm pregnancy, because if the woman tests
positive and they provide treatment, they would be inducing abortion, and would therefore be
on the wrong side of the law. This perhaps is the reason why they do not want to take the risk
of conducting tests. Besides these, another reason might be that since the informal providers
are mostly male, women are not comfortable in undergoing check-ups by them. Moreover,
the place from where they provide services does not have any privacy for check-ups.

7

One of the women opined that tests were not necessary, because women generally
know they are pregnant and do not want to continue with the pregnancy, therefore it is
convenient to seek treatment for delayed menstruation, without any pregnancy tests. She said,

No, no tests or check-ups are done. Test for what? When the woman has already
decided and wants to abort.
A few women also mentioned the availability of pregnancy strips in their villages to
test pregnancy. Said a woman from village A:
I came to know that there is a bottle to test the pregnancy, if it shows two lines it
means you are pregnant. It costs 40 rupees.

Regarding the efficacy of the “hot medicines” provided by the village doctors, women
reported that it might or might not be effective, depending on how long the periods have been
delayed. As reported by one of the women,
The doctor in the village gives medicines if the period is delayed by only 5-10 days or
a maximum of one month but not beyond that. Beyond that one has to go to Jind.

Services provided by dais for delayed menstruation
The participants were asked about the role of dais and the type of services or treatment they
provide to women who approach them with missed periods. The immediate response from
some women was,
"'the dai tells you the same things that our elderly women tell us

All participants, males as well as females denied that dais in their village use any
other methods like tablets, injections or instruments for treating delayed periods. In their
opinion, dais only recommend things that are well within their domain, namely; traditional,
home-based remedies like hot foods and kadhas. Trying out any other method they are not
familiar with would be too risky for the dais. This is reflected in a succinct response of a
woman from village B:
Why would she want to dig her own grave? Obviously it is the doctor who will do it.
The dai only tells you about the kadha. It is up to you to decide whether you want to
take this kadha that she has recommended.
Miscarriages

In the case of bleeding during pregnancy or miscarriage, as reported by the participants,
women in their villages mainly go to formal providers in the city, while some try home
remedies like kadhas first. If this does not work they go to the informal providers in the
village or to the formal providers in the city for ‘safai’ (curetting after spontaneous abortion
or miscarriage).
Women in one group discussion mentioned that these kadhas are meant mainly for
minor problems like pain during menstruation or during pregnancy. If these do not work the
woman would have to go for “safai” from the formal providers in the city.

8

Some women said that women do not always rush off to the doctor as soon as they
have pain or bleeding, they first wait for it to subside and if it does not, they make
arrangements to go to the providers based mostly in the city. According to a woman
participant from village B, waiting can be fatal, but this seems to be their lot to suffer the
pain. In her words,

When there is no other choice and they become helpless, only then do they go to Jind
(to the formal providers) otherwise the woman has to bear the pain here in the
village. Whether she die in between who cares. (Jab lachar ho jayai tab javain Jind
nahin to yahin pair pittain akhair main javain. Rah main mar bhijavain chahe)
Some of the participants also mentioned that the advice of the informal providers like
dai and the ‘doctors’ in the village is also taken in the case of miscarriage. These informal
providers mostly advise them to either try kadhas or give them medicines The dai also
advises the family to take the woman to a formal provider.

Dais may also provide “safai” (curetting) after miscarriages, but only in the presence
of the village doctor, which is evident in the response of another male participant:
Suppose a woman has started having abdominal pains and miscarriage we call the
doctor in the village to do safai (complete abortion). The doctor gives medicines. He
charges 25 rupees for the home visit and rupees 100 to 150 rupees separately for the
medicines and safai.
Abortion
As discussed in the earlier section on abortion services available to the community, women
who want abortion mainly go to the formal providers in the city, who are expensive but
considered effective. Here it needs to be mentioned that treatment of miscarriages and
spontaneous abortion as well as induced abortion are referred to as “safai” (cleaning). As
both procedures are invasive and surgical, the community preferred to go to formal providers
because they were better equipped to handle these cases. Moreover, invasive procedures are
used only by formal providers in the cities.

Though both men and women participants reported that abortion services are mostly
sought from the formal providers in Safidon and Jind, some of them also reported that some
women in the villages try to induce abortions by drinking kadhas.

Kadha is taken for both to resume the cycle and to avoid the child as well, (a female
participant)
If a woman does not want child and she missed a cycle then she drinks it.
(a male participant)

If they (women) do not want to have the child then they have to take kadha.
(a female participant)

9

Kadhas however, are said to be effective in inducing abortion only of pregnancies in the first
trimester.
The kadha can abort a pregnancy of one and half to 2 months, (a male participant)

Similarly, intake of “hot medicine” is also said to induce abortion, as mentioned by
one of the women:

Women who want a child will not take the hot medicine.
Another woman reported the presence of a doctor in her village, who provides
medicines to induce abortion.

There is a doctor in the village. He can tell by touching whether pregnancy is there or
not. He also gives medicines to induce abortion (girane ki dawa bhi de deta hai) at
the cost of50-100 rupees. If it does not work then one has to go to Jind.
Regarding the type of abortion services provided by the formal providers, some of the
female participants reported that in the initial stages of the pregnancy even these doctors use
medicines or injections to induce abortion, but if the pregnancy is more advanced, i.e. more
than 2 months, they use surgical methods. According to these women:

They give hot injections (Garam tikkai lagatain hain)

First they give medicines and if the pregnancy is of more number of days then they
abort it (safai).
Formal providers conduct urine tests and physical examinations before they provide
abortion services. The women described the procedure adopted by the formal providers:
First of all the doctor examines the woman and then does urine test, only then he
gives medicines.

One has to take a urine test and then she (female doctor) gives treatment. She will tell
you ifyou are pregnant. Ifyou want child then fine otherwise you have to abort it.
Some of the women participants also mentioned that women themselves would ask
the formal provider for urine tests or medicines. In the words of two women,

Tell the doctor that you want to get an abortion done and ask them for hot injection
(garam tekkai)

Go and get urine tested by the doctor and askfor hot medicines.

Role of the Husband
A study by CORT (1998) has shown that women who did not get the support of their
husbands for abortion were more likely to try out indigenous methods and self-medication to
induce abortion. Thus the role of the husband in decision making for abortion as well as the

io

kind of support they extend to their wives need to be understood as it also determines the
pathway to abortion.

Decision Making in Abortion

Most of the females were of the opinion that a woman has to take permission from her
husband for everything that she does and would like to do, she cannot go for abortion without
his knowledge or permission. According to them:
The husband makes all the decisions.
A woman cannot go without her husband’s permission.
If the husband does not agree for an abortion then a woman cannot go

One of them recalled her experience, her elder brother in law was against the abortion
and influenced the husband, who then refused to let her have abortion.
Other than family members, according to a few women, even doctors might decide
whether the woman should continue with the pregnancy or not.
I had a son and a daughter and I do not want any more children. He (husband)
refused to let me get the child aborted. My elder brother-in-law was against it.
When asked whose decision would prevail in a situation where the husband wants to
keep the pregnancy and the woman wants an abortion, all the women in the groups said that
the husband’s decision would prevail, because “the woman has to obey her husband”,
“without his decision she is helpless”. Women generally give in, because if they disobey they
would have to face the consequences like:

He will start beating her ifshe would not listen to him

He will send her to her parents ’ home and will not allow her to stay with him
He willforcibly take her to Jind (for abortion)

The response of the men to the same questions was very much in contrast the
women’s response. While women say that husbands are the decision makers, and these
decisions are unilateral, men say it is a joint decision. Interestingly, men reported that
husbands would never force their wives to keep the pregnancy or undergo abortion in order to
avoid marital conflicts. As one of them put it,
If the husband just says to the wife, go and get it (abortion) done, and the wife says I
won’t do it, then there will be quarrels.

Support in seeking abortion
It was revealed that men generally do not accompany women, “a man does not like to go with
his wife”, but they might arrange for a female person to accompany the woman. The
accompanying person may be a sister-in-law, a neighbour, or any known female.

11

w

The husband will ask somebody to take his wife, he will not go himself (a participant
from village B).

He (husband) does not go along with his wife. He will ask his sister or neighbour or
her sister-in-law or mother to go with her (a participant from village A)
Generally women felt that men do not accompany them for seeking treatment of such
problems because they feel “shy”, embarrassed rather. The only support that men reportedly
give is by bringing or buying them the prescribed medicines. As mentioned in the earlier
sections, men are ignorant of the reproductive health problems of women; this could be a
reason for the lack of support to their wives in seeking abortion services.

12

Informal Providers
Not much was achieved in the group discussions
held with the ANMs of the PHC and the informal
providers. The researchers observed that the
providers were very reluctant to talk about the
study issues, which they considered sensitive and
very confidential. They felt they could not part
with such information about their villages to
“outsiders” (researchers). The general view
seemed to be “matters of the village must remain
in the village”. The ANMs avoided talking
about the issue and outrightly denied performing
or providing any abortion related services
possibly because they were aware that they are
not authorised to do so. They said they always
refer all clients who come for abortion.

Profile of Informal Provider

Characteristics
Age (in years)
<25
26-30
30 +
Qualification
<5
10
10+2
Under Graduate
Informally learnt with
formal provider
< 3 years
4-5 years
5 + years
Providing the services
< 3 years
4-5 years
5 + years

N=7
2
3
2

1
1
3
2
the

3
2
2

3
Seven informal providers (six male
1
village doctors and a dai) were interviewed. All
3
providers were literate. Among the village
doctors, three had studied upto class 12, while
one of them had dropped out of the GAMS, two had completed matriculation and one was an
undergraduate. None of them had any recognised professional qualification. They had learnt
medical practice by working with the qualified formal providers in the city. The average
duration for which they had worked with doctors and gained experience was 4.3 years. All
the six providers had one room clinic called ‘Dukan’ (shop) from where they offered their
services. The services offered by them included treatment for general illness like fever,
vomiting, diarrhoea, injury, malaria etc. It was only after probing that all the informal
providers reported that clients also come for treatment of gupt rog (STD) and menstrual
problems.

Treatment of Delayed Period/Abortion

Out of the total informal providers interviewed, four provided treatment for periods delayed
up to a maximum of three months, while two of them said that they deal with the cases of
delayed menses only up to 20 days. The type of treatment that all the informal providers
offered included medicines or injections to abort the pregnancy. None of them mentioned any
use of instruments for invasive procedures. The same was reported also by women in the
FGDs, who stated that informal providers in the village provide garam dciwa (medicines) or
garam tikkai (injections). The dai said that she only advises for concoction (kadha) and
nothing more than that:

Ifsomebody comes to me I only tell her about the kadha - This includes carrot seeds,
cottonseeds and old jaggery and ground lentils, which is boiled with one glass of
water.
The village doctors believed that medicines and injections do not work for
pregnancies beyond 2 or 3 months. The case becomes more risky and they do not handle such
cases. Then they suggest these women to go to city for the required services. In their words:

13

I treat woman who are 2 months pregnant at the most, beyond that, I send them to
Safidon. More risk is involved in such cases and medicines do not work, so it is better
to send them to Safidon.

It is a matter of village, we cannot cross our limitation, we have to stay in the village.
We only provide medicines and injections, if it does not work then we suggest them to
go to the city.
It should be noted that the informal providers do not openly acknowledge that they are
providing the abortion services, instead they refer the related services as regulation of delayed
menstruation and for this they provide medicines and injection, often without confirming the
pregnancy. The reason as one of the providers reported:
If a woman has delayed periods even for two days she knows whether it is pregnancy
or not. Only in few cases, delayed menstruation could be due to other reasons such as
anaemia. Otherwise in most of the cases delayed menstruation is because of
pregnancy.

During the in-depth interviews, only two village doctors mentioned that they conduct
pregnancy test using the pregnancy test strip and then provide medicines or injection to
induced abortion, but again this was not referred to as abortion. These providers reported that
these pregnancy strips are widely available in the village. The same was also reported in the
FGD with women.
Almost all the providers offer Erga cap with combination of other medicine. The
combination varies. The reported combination of medicine and their dosage is as follows:
■
■
■

Erga cap + Reguline, twice a day, for two days
Erga cap + Methegine cap, thrice a day for three days
Erga cap + Lariago, twice a day for three days

If these do not work, then they administer Prostodine injection. Bleeding is reported
to start within two to three hours of administering the injection. The following verbatim
emerged during the discussion with a village doctor:
If a woman comes with a problem of delayed menstruation, I give her tablets first. In
50 percent of the cases they get their cycle back. I give Reguline and Erga cap, two
times in a day for two days. Then I wait till one week. If the menstruation does not
start within a week then I administer Prostodine Injection of 1 ml, in rare cases 2 ml.
is given In 90 percent of the cases it works.

The village doctors were well aware of the side effects of prostodine injection. Hence
according to them they inform the woman in advanced about the side effects. Before injecting
prostodine they do take measures also. According to a provider:
When I administer injection, I tell the woman that after giving this injection you
would start vomiting and have loose motions. To avoid this, first I give them medicine
to prevent vomiting and only then I inject. Because, after taking the injection if a
woman starts vomiting then the injection will not be effective, so we take precaution
before giving the injection.

14

The village doctors are confident in providing the services and have so far not faced
any problem. They never guarantee the effectiveness of treatment. Some of them stated that
the line of treatment they follow is generally similar to that provided by formal doctors in the
city. As one of informal providers shared an incident:
I gave an injection to a woman but it did not work so I advised her to go to Safidon.
She went to doctor Meera (name changed). Doctor Meera also must have given the
same Prostodine injection because she had not aborted. Her period started within 15
days, the woman told me this when I enquiredfrom her.

Probing further on charges they charge, the providers reported that if they provide
only medicines then they charge Rs. 80 to Rs. 100/- and for the injection they charge Rs. 150
to 200/-.
The village doctors mentioned that generally husband knows about the treatment for
delayed period. Some times the husband themselves come to the dukan (clinic) to take the
medicines for their wives. Only in some of the cases women want to keep it secret especially
from their in-laws. In such situations they do offer the services but in the name of some other
menstrual problems. According to a village practitioner:
Once a pregnant woman came to me. She did not want the pregnancy, but her in-laws
were against the pregnancy to be aborted. She asked me to keep it secret. 1 gave her
an injection and told her in-laws that I am treating her for excessive bleeding.
Because injection cause a lot of bleeding. In this way no one could know the fact and
the pregnancy was terminated successfully.

Attitude towards Abortion
All the informal providers opined that abortion is wrong and it should be done only if the
pregnancy is the result of rape, the woman has serious health problems, and the foetus is
undeveloped.

Conclusion
Overall, from the discussions with the community regarding the pathway women take to
select an informal provider, the picture that emerges is that:
♦ for delayed menstruation (suspected pregnancy) the first step is to try out home­
remedies, hot foods like kadhas. If it fails, women contact the “village doctor” (gaon
ka doctor) who gives them hot medicines (garam dawa) and injections (garam tikkae).
If this also fails, they go to formal providers in Safidon or Jind.
♦ for (possible) miscarriage, i.e., bleeding during pregnancy
(garbh ke3 samay
,
mahavaari), they mostly go to formal providers in Safidon and Jind, but not before
having waited for at least two days. Some consult the dai and/or the village doctor for
stopping the bleeding or for “safai” (in this case cleansing after miscarriage).

15

♦ for “safai” or abortion, they mostly go to the formal providers in Safidon or Jind.
They understand “safai” in this case abortion, as an invasive, surgical procedure, and
are well aware that the (informal) village providers are neither experienced nor
qualified to provide abortion. So they prefer to directly approach the formal providers.
They even know formal providers by their names.
It was also found that women who are economically better off (most of them are from
the Jat community) generally go directly to the formal providers in Jind, they only approach
informal providers in the village if, the problem is not considered as serious, while those from
the socio-economically backward communities generally approach the informal providers
first.

Abortion is considered a sin by both the community and the providers. This is
probably why a possible pregnancy is referred to as delayed menstruation in the community
and is treated accordingly with concoctions, medicines and injections from the local informal
providers. The providers on their part avoid using the word induced abortion and refer to it as
menstrual regulation.

Recently the Govt, of Haryana has taken strong steps to enforce the PNDT Act by
cracking down on sex determination clinics and providers. The wide publicity that these
effort have received, have contributed to increasing public awareness about the ban on sex
selective abortion. However this has also led to confusion in the community as well as the
informal providers regarding the legal status of abortion. They believe that ban on sex
selective abortion also applies to abortion.

The community is well aware of the capacity and competence of the informal
providers in their respective villages, they know what kind of cases these providers can
handle. The providers on their part are aware of their limitations and refer cases they cannot
treat to the formal providers in Safidon or Jind.

16

References

Khan, M. E., Payal Khanna, Ranjana Sinha, Bella C. Patel, and Seema Lakhanpal. 1998.
Decision-making in Acceptance and Seeking Abortion of Unwanted Pregnancies, paper
presented at the International Workshop on Abortion Facilities and Post Abortion Care in the
Context of RCH Programme, March 23-24, New Delhi.
Indian Council of Medical Research (ICMR). 1989. Illegal Abortion in Rural Areas: A Task
Force Study. ICMR: New Delhi.

Chabbra, Rami and Sheel Nuna. 1994. Abortion in India: An Overview. Veerendra Printers:
New Delhi.
Centre for Operations Research and Training (CORT). 1997. Situation of MTP Facilities in
Uttar Pradesh. CORT: Baroda.
1998. Decision-making in Acceptance and Seeking Abortion of Unwanted Pregnancies,
paper presented at the International Workshop on Abortion Facilities and Post Abortion Care
in the Context of RCH Programme, March 23-24, New Delhi.

1989. Illegal Abortion in Rural Areas: A Task Force Study. 1994. Abortion in India: An
Overview.

17

tAi H -

«•

Providers of Indian Systems of Medicine
• Total providers
• Male
• Govt job 28.4%.

63
98.4%
Private 71.4%

Qualifications (as n’eported by practitioners):
• BAMS
46
• BHMS
05
• BUMS
11
• DHMS
01
States to which they belong:
- Rajasthan:—
76.2%
- West Bengal:
7.9%
- Other states:
15.8%

Treating delayed periods
Acknowledged treating women with delayed periods; 73.0%

Methods used:
- Herbs/ decoctions:
1.6%
- Tablets:
60.3%
- Injections:
28.6%
- Use instruments:
^.8%
- Other
11.0%
Type of instrument used (n=3): Curette/ D&C
Max Gestation up to which evacuation done: 4.3 months (2-8)
Average amount charged per case: Min: Rs 300 Max: Rs 600

1

-

Other services provided by ISM providers:
♦ Injections:
• IV fluids:
* Stitches:
• Deliveries:

* Incomplete abortions:
Common problems seen

85.7%
76.2%
71.4%
30,1%
74.6%

— Women:
- “GuptRog”:
- Menstrual problems:
- Weakness, anemia:

50
31
27

2

Practices of Informal providers

Profile on informal providers interviewed
• Total:

618

• Mean age:

37.8 vrs

• Sex: 38 % Female;' 62% male
• Educational background:
- Illiterate/ primary;
58 (9.4%)
— Middle'7 High school:
375 (60.7%)
- Graduate and above:
185 (29.9%)

1

Category of providers (n= 618)
ANM/LHV/ trained nurse
Compounder/male nurse/
male health worker_____
Lab technician/ chemist
RMP/ untrained
practitioner
Peon/ untrained nurse
Dai

203
103

32.8%
16.3%

3
258

0.5%
41.7%

5
46

0.8%
7.4%

States to which providers belong
• Rajasthan
• Kerala:

74.6%
11.6%

• West Bengal:

8.9%

• Other states:

4.8%
Government/ Private job
Government job:
Private :

45.8%
54.2%

2

i

Treatment of delayed periods
Acknowledged treating women with delayed
periods: 66.1%
Types of treatment (by those who treat delayed
periods)
- Tablets:
79.9%
- Injections:
53.3%
- Instruments:
6.3%
- Herbs:
6.6%
- Message:
1.9%

Perception of success of various methods

Providers who felt method is successful in >
50% cases
- Tablets (n= 329):
21.4%
- Injections (n= 219):
65.7%
- Herbs: (n= 27):
29.6%

3

Use of instruments (n=26)
Types of instruments used:
Curette:
23
Catheter:
1
Copper-T :
1
Syringe:
1
Max gestation up to which instruments are used:
-2.7 months (range 1-8)
Average number of cases per month: 5.8
Average amount charged per case:
Average min: Rs 286, Avg max: Rs 509

Range of other services provided by
informal providers
• Injections

90.4%

• IV fluids:

84.4%

• Stitches:

61.4%

• TT injections:

78.6%

• Deliveries:

54.3%

• Incomplete abortions:

59.2%

• Menstrual problems:

66.1%

4.

Workload and common problems treated

(n=618)
• Daily caseload:
12.1
• Work on 7 days a week:
82.8%
• Provides services 24 hours a day: 44.3%

Most common problems treated;
• Children: Respiratory problems (84% ),
Vomiting, diarrhea (62%)
• Men:
Fever (67%), Pneumonia (51%)
• Women: “Gupt Rog” (65%), Vomiting etc (52%)

5

Situation Analysis of Abortion
Services in Rajasthan

|
|

8888888888^888^8888888888888888^

Action Research & Training for Health
(ARTH)
Udaipur

General objectives
Assess availability & adequacy of
abortion services in Rajasthan
Assess institutional readiness for
delivery of quality services

i

Specific objectives
Map availability of abortion services
Outline organization of services and
linkages to RH services
Study techniques, processes related to
training and certification
Institutional readiness — capacity,
technical and interpersonal quality
Cost of services

Study design & sampling
** Cross sectional study of abortion providers
and facilities

* Two districts selected purposively (Jalore and
Kota)
* Cluster sampling - three blocks per district

Listing of all facilities in sampled blocks

Qualitative assessment of arrangements for
certification and training

2

3888888888^^^

Study team -1
Team of four persons for listing and
informal provider interviews. Male­
female investigator pairs used 2wheelers to visit villages / wards
Formal providers - Govt HCs by
members of the above team, private
facilities by a medical doctor (gyn /
public health) and nurse/ social worker

X

Study team - 2
Data coding by office research staff
including oversight by a gynecologist
(for open codes)
Double data entry by DEOs
Analysis by principal investigators

3

* S8fi8888888r-^::^:: 888am:SW*

Ethical considerations
ARTH’s IEC reviewed the proposal at the
start and during the course of the study
Study objectives were camouflaged during
listing and informal provider assessment
Verbal consent with handover of signed form
* Interviews in private
* One section of IP form was canvassed
verbally and respoonses filled after interview

Listing process-1
* Complete enumeration of providers in all
panchayats / wards of the cluster
Two teams visited each panchayat / ward and
inquired from key informants and village
women
Converged to the subject abortion - health
providers > services for women > delivery >
menstrual problems > delayed periods

4

-<>>:-:-<:y:>^»^^'

...wx<.:.:,:. s»s«SM».w.:.!w.:.! «8888888g^y^:^- 388888888&::X:;^

Listing process - 2
Providers classified as “not abortion
providers”, “possible”, “probable” or
“definite”
Major techniques employed were also
ascertained
Secondary information sources also
consulted for formal allopathic providers

F5J^O

X<%%wX«

:W

Eligibility of providers
Eligibility depended on provider
category
All apparently unqualified practitioners
(“bengali”, “gujarati”, etc)
* AH gynecologists and general surgeons
Among the rest, all those who had been
listed as possible, probable or definite
providers

5

Phases of data collection
First phase - listing (no official contact)
* Second phase - informal provider study
and revision of lists (no official contact)
Formal provider study (official contact)
Qualitative assessment at state level
(official contact)

Dealing with ethical issues-1
Discrete, rapid listing process relying on
multiple informants
Informants’ evidence was not shared
No official contact during listing process
Three stage data collection
Dealing with providers’ spouses - at
times, spousal consent and participation
became inevitable!

6

Dealing with ethical issues-2
Post-interview filling of a section of the form
to avert attempts to monitor written responses
* Formal providers - detailed questioning about
investigators’ credentials
’r The “Udaipur factor” facilitated the consent
process among formal providers of Kota
At times, the theatre nurse was not allowed to
respond independently. However, some did
give information that varied from that
provided by the administrator or provider

KWSSSJSS:

ISM providers
* Often difficult to recognize true ISM
practitioners - type of facility, drugs on
display, etc
Claims about being qualified as homeopaths
- doubtful degrees, Inability to clarity, not all
had name boards
Most used tablets or injections, not
instruments
* On disclosing study objectives, the three who
acknowledged use of instruments then
denied abortion service provision. Hence
informal provider schedule was canvassed

7

VO VA -

.

Shramik Bharti-Healthwatch

Executive Summery
About Shramik Bhartr

Act and also under the Foreign Contribution Regulation Act

Sur

h S^arT S ' TV V and nOn-f°rmaI

ch
—^icr^^

motherhood
and care lor the aged.
-------------

Area Profile:

J^PreseJlt.Study.was conducted in ‘Maitha Block of Kanpur Dehat’
distrct, which is situated at a distance nf
Vm r
tz
are lower caste, having a low female literacy and sex rah? Sd a S
maternal and infant mortality.
d
h gh
Regarding public health infrastructure, though two PHCs existed none of
IVT
°r Staffed
hMdl'! Vgenc.es or pXde care h
required. Private Practitioners do proliferate in the
Th
♦
referral facilities, including a leading medical coTge Vm

Methodology:

largely qualitative being exploratoiy i
limitation of time and
resources in the study. Once respondents eligible
for different categories were determined for the final selection as per the
desired sample size, random
.1 jsampling was resorted to. This to some
extent helped in reducing
reducing subjective elements and ensure
representations.

The Respondents:

The respondents for the Study included
'
women who have undergone
abortions with whom the data wc
. was collected through in-depth interview
[IDI’s]. Focus Group Discussions
’—7.7J [FGDs] were conducted among other
women from the community like the quite elderly
wr women, less aged

1

Shramik Bharti-Healthwatch
women and the adolescent girls. A FGD with men in the community was
conducted in order to capture the men’s perspective of the problem.

Besides, the Community people, the health care providers ho provide the
abortion services or would be able to give information of these were also
selected. Data was collected from them using IDIs/FGDs.

Different categories of respondents studied, the research technique used
to collect data and sample covered in the study are given in the following
table:
Category of respondents

Research
Technique
IDI

Sample covered

FGD

2

FGD

1

Adole scent girls
Care providers who do
abortions
Informal care providers

FGD
IDI

2
6

IDI

6

Information providing
functionaries

IDI

4

Rural health care providers
Rural men

FGD
FGD

9

Women who have
undergone abortion
[
[Quite Elderly women

7

With rural women of less
age

T

Reasons for Induced Abortions:

Most of the women who have undergone abortions had done so mostly in
cases where they had not wished to conceive.

When a women conceives unwillingly and cannot afford the expenses
sure of bringing up yet another child, this is one way to solve the
problem. Many women resort to this risky solution when they conceive
through socially unacceptable ways. Among such women are included
unmarried girls, widows or those whose husbands have been living away
from home for quite a long period of time.

2

. Shramik Bharti-Healthwatch

Period of Abortions:
The pregnancy period when abortions are sought is between 3rd to as late
as 7th month of pregnancy. The unmarried girls were reported to resort to
abortions of time at a late stage of 4th or 9th month of pregnancy.
First Action Taken in Unwanted Pregnancy:
Before deciding for abortions either from illegal or legal sources, most of
women attend home remedies. She would eat hot things like Jaggery,
seeds of castor, sour things like vinegar.

The midwives are usually the first to be contacted for advice or medical
help.

The home remedies are opined not to work well by all categories of
women respondents. As commented by a woman "Though the bleeding
starts, it does help in full clearing”,
Health care providers Conducting Abortions:

The women having unwanted pregnancies seek help most often from the
Local Doctors [RMPs, Jhola Chaa Doctors or Bengali Doctors as they are
called in some places here], ANMs/Nurses, Midwives, Dai’s.
The money spent varies for married and unmarried women Rs. 100-Rs.
300 per abortion for married women and Rs. 2000-Rs. 5000 for
unmarried women.

In a year, around 15-20 women were reported to go in for unsafe
abortions and of these atleast 2-4 cases are spoiled, the secure ones
leading to the death of the women.
All providers accepted and reaffirmed the fact that they do and need to
maintain confidentiality of their abortion clients.
Awareness of Law:

All providers were observed to be quite aware of the law against
conducting abortions. However the trained ones gave the excuse that in
villages, people do not allow them to follow the law; they start howling and
crying and catch hold of their feet to compel them to conduct abortions.
One provider directly said no to her knowledge about the law while
another appeared to be frightened. She said that a person conducting
illegal abortions can be imprisoned for 7 years and that is why she is
closing this practice.

3

Shramik Bharti-Healthwatch
CHALLENGES FACED:

The investigating team faced difficulties in getting the respondents. The
women who had undergone abortions would not disclose their status how
did you know about them? and / or would be unwilling to talk. They were
handled through Village Health Guides (VHGs) who were associated with
SB through the Sanjeevani project. VHGs live in close proximity to them
and come from the same community as the women seeking abortion
services. The VHGs are able to identify such cases since the women do
come to them for seeking advice or there are certain obvious reasons
which help them to know these women viz. if they knew that the woman
was pregnant and suddenly the pregnancy vanishes. VHGs helped in
getting to such women and facilitating the process of rapport building
and then interviewing them.
Similarly the providers who provide abortion services were not willing to
accept that they provide such services. A Doctor who has been providing
abortion services for quite a long time and was cited by several women
didn’t accept to be a provider of such services. For those providers who
became the respondents for the study did so only after they were assured
of non-revelation of their identities and maintain anonymity.

The women respondents who participated in the study were not able to
tell the names of the medicines and injections given/ prescribed to them.
The providers did tell but the main doctor who was reported to provide
the services did not participate and hence all the names could not be
known.

Time management also posed some problem. The respondents were
unwilling to sit through long sessions as required for successful
completion of the interview as per the designed interview schedule. So at
times the interviews were hurried and much time could not be spent on
probing which could have further enriched the data collected.

CONCLUDING REMARKS
It came out very clearly through this study that a very large number of
women, even from the poor, rural communities go for abortion atleast
once in their lives. A large number of women have to go for abortion more
than once in their life time.
The major reasons for this appear to be the desire not to have more
children. The burning desire for male child is also one of the reasons to
go for abortion if women come to know through medical investigations
that the child in their womb is a female one.
The failure of family planning methods is also one of the reasons for
opting for abortion.

4

Shramik Bharti-Healthwatch

Two important factors contributing to the high number of abortion are:-

i)
ii)

Lack of knowledge or non-availability of family planning
methods to poor rural women despite there being a felt need for
that.
Lack of information on sex related matters among adolescent
girls, which lead them to be drawn into unwanted and
humiliating situation.

The main reason for not going to professionally competent and qualified
doctors is their being expensive and at times unapproachable. The myth
that locally available experts> can also do the job and at much less cost is
also a contributing factor.
What has come out clearly that women, including adolescent girls, suffer
a lot, physically as well as emotionally, because of the consequences of
unsafe abortions and most of the times, end up by spending much more
money than what they would otherwise do if they were dealt by
professional hands. The need is, therefore, to increase the level of
awareness and knowledge through community education programmes
and also to create more professionally managed facilities, which are
reachable to poor rural communities.

The matter deserves utmost attention by policy-makers as it involves lifethreating propositions.

************

5

M

-S

Executive Summary - Dr S.K.Mishra
One of the major causes of maternal mortality is “Unsafe Abortion”, which account for
nearly 20% of all maternal deaths in India; around 40,000 each year. It has also been
observed that about 6 million abortions take place every' year of which 4 million are
induced and 2 million are spontaneous abortion.

Keeping this in view. Ford Foundation (U.K.) through CEII AT. sponsored a Multicentric
Study in 6 states of the country. These states are Haryana, Rajasthan, Mizoram, Kerala,
Madhya Pradesh and Orissa. The Child In Need Institute (CINI) Kolkata is’the co­
ordinating agency, responsible for the study entitled “A Multicentric Study on Provider
Related Issues In the State of Orissa”.
Prior to the start of this study, CINI has constituted an Institutional Ethical Committee
consisting of 7 members from different backgrounds that ratified the final proposal and
protocols.
To get a picture of propensity towards abortion in the State of Orissa, the districts of
Sgmbalpur and Mayurbhanj were chosen for the study depending on the five variables
viz. sex ratio, female literacy rate, IMR, Institutional delivery and total fertility rate. The
idea was to see the difference between the betterjieiformin^XSamhalpur) and the poor
PSrformmg districts (Mayurbhanj), since socio-economic factors contribute to the state of
education and general awareness. The need for abortion, not a woman friendly method is
expected to be less if the factors above are favorable. Three community development
blocks from each district were chosen on the basis of urbanization for the study All
public lacihties, private facilities and community providers were enumerated and
enumerated providers were asked for their willingness to participate in the study. Only
those agreed to participate in the study were interviewed. Participants were interviewed
in a closed-door setting with
' One
at a t'me ar|d !'ley were assured that their
comments would not be disclosed.
------ The
...c names of the participants were no taken at the
time of analysis.

Out ofP a total“ population
poPl‘lauon of 36,70,692, 86.62%
86.62% are rural with female literacy of 34 8%
y_I ercentage of contraceptive prevalence and institutional births are low-41 64 and
I 9.07 respectively. But the number of MTP performed annually is as high as 25 320 The
87 respectively. But the alarming aspect is the existence of 49 (may be more) inform^ II
fee.foies i.e. those wbrah are not certified and do not have formally trained prov£ '
Justification offered by these is that
They were not told about the need for certification.
Application forms were not given to them
Applications were lost by the certifying authorities,
I oo many objections were raised and harassed and
Refused certification.

X

As a result, the private facilities (though some are certified) do not at all report the
abortion cases. The record of the public facilities also is not too good in this matter.
In the public sector, however, consent of the clients (or of their family members, at least,)
is taken in 100% cases. But the record of the private facilities in this regard is also bad;
Consent is'Taken in 38%__cases only. Details about abortion process, anaesthesia,
analgesia, etc. are given in the consent form for the client’s knowledge prior to the risk
she is taking.

Physical facilities, like waiting area, beds, toilet, water, electricity, etc., are best - of
almost 100% satisfaction - in all the districts and private certified hospitals. Availability
of basic equipments, anaesthesia related equipments and sterilization/infection prevention
instruments is more or less satisfactory in these hospitals. But the availability of drugs
and other consumables is at a pathetic level (varying from 17-32%). There is an absence
i \ of work culture in the public sector and therefore, service gets postponed - more
' alarmingly at the PI 1C levcty- because the equipments are out of order or the instruments
arc not sterilized.

An overwhelming majority of the providers in thejmblic sector are full time, i.c., on staff,
where as in the private sector all are on call. The later does not have providers for other
than MTP purposes. Anesthetists are also only on call. A majority of the nurses in both
the sectors are only diploma trained and the percentage of degree-qualified nurses is
slightly higher in the certified private facilities. Half the non- certified ones do not have
nurses at all.
The public sector has not only a higher number of formally trained providers, but also a
higher number of those, who are trained in

Counseling and 1PC,
Universal precautions and
Reproductive health and rights.
All types of facilities provide MTP for pregnancies up to 12 weeks. They become
selective after that. No abortion takes place beyond 20 weeks. Emergency services, like

S Facilities open 24 hours,
Providers available any time,
Management of excessive bleeding, perforation
complications, are better in the public sector.

peritonitis

and

other

The performance of this sector is better also with regard to reproductive health services
like antenatal and post-natal care, contraception, infertility management, treatment of
STD/HIV, etc. There are referral arrangements with other specified or better-equipped
hospitals. A thoroughly disappointing fact is that no private facility has medical
guidelines with them and only 1 3% of the public facilities have. This is a reflection of the

X

/

poor awareness and poor sensitivity of the providers and how casually the clients, i.e.
women, arc treated.
Techniques used for abortion in different trimesters are many. But EVA, D&C and D&E
are most popular. Analgesia/Sedition is the most commonly used pain control method,
followed by local anaesthesia. But in case of abortions of pregnancies of 13-20 weeks,
the latter is practiced more. Pre-discharge examination is not satisfactory since it is only
general in majority of the cases. The necessary drugs like iron and vitamins, arc rarely
prescribed, the most common being the anti-biotics. The providers seem to be concerned
with the immediate cure only. They forget that reproductive health is a life-Timc-pixrcess
of a woman. This attitude is further obvious in the fact that post-abortion counseling puts
least importance to the diet and work of the woman and most to contraception and poSabortion medication.
7 ---- ---------

Insensitivity to woman while counseling comes out glaringly in Table-46, where we find
that tubectomy, the most harmful and dangerous method of contraception, is ranked as
most popular. Obviously women do not opt for it; they are forced into it because men
refuse to go for the harmless methods of condom and vasectomy.
One plus point is that 81 -86% of facilities are within the easy reach of the clients, i.e. on
the road and within a kilometer. Arrangements for commuting are also good. Buses and
jeeps are the popular mode of transport.
rhe cost of MTP varies from sector to sector and according to trimester. Higher the
number of weeTs of pregnancy, higher is the risk involved in MTP and therefore, the rate
of MTP is also higher. And, it is everybody’s knowledge that the cost is much lower in
thejxiblic sector facililies.Jl-Can be as low as Rs. 57 (in the public sector) and inThigh as
Rs. 1250 (in the private facilities). Besides, the charges by the public facilities arc
generally inclusive of the cost of the ancillary’ services.
The worst problem faced by the clients in their discomfort and inhibition due to the fact
that there is hardly any female provider. Notwithstanding the fact that the providers are
conversant in the local language, the women patients find it difficult to communicate with
the male doctors.

Almost 100% of clients to the private facilities are women with a social stigma, viz.
unmarried,\yiilQwed, separated and deserted. Public facilities too, get 80-87% of such
clients. So, one can understand how important is counseling about reproductive rights and
gender equity. Then only women can fight such demeaning situations better.
p

The absence oi^ender awareness is visible in the fact that there are untrained providers
of MTP? Some of them are even illiterate. They are kind of Jack of all trades and attend to
snake bites even.

r

Y\

Proposed Agenda
Abortion Assessment Project - India
Research Report Sharing Workshop
May 22 to 24 2003
St. Marks Hotel, Bangalore
Chairperson / facilitator /
discussant

10.0010.30
10.30 to
11.30
11.3012.30

____________________ 22 May 2003
Introduction to the project (mapping all the
research studies)
Multi-centric Studies
Presentation 1,2,3

Discussion

12.30-1.30

Presentation 4,5,6

1.30- 2.30
2.30- 3.30

Lunch
Discussion

Community based surveys__________
Break___________________________
Key issues emerging from the studies analysis for synthesis report_________
____________________ 23 May 2003
9.30-10.00 Policy Review - Siddhi Hirve_______
10.00Discussion
10.30
__________Qualitative Studies
10.30Introduction to Qualitative Studies
11.00
11.00BREAK
11.30
11.30Presentations on Informal Providers Study 12.30
1,2, 3 (BVS, SORT, Swaasthya)_________
12.30- 1.00 Discussion__________________________
1.00-2.00
Lunch______________________________
2.00-3.00
Presentations on Informal Providers Study4,5,6 (ARTH, VGKK, Shramik Bharti,)
3.00-3.30
Discussion__________________________
Key issues emerging from the studies 3.30-4.00
analysis for synthesis report

3.30- 4.30
4.30- 5.00
4.30- 5.30

Ravi Duggal and Vimala
Ramachandran

Kerala: Padmini
Swaminathan
M.P.: Bela Ganatra & Ulina
Sen
Haryana: Sudha Tivari &
Syeed Unissa___________
Chair:

Mizoram: R.N.Gupta
Rajasthan: Dinesh Aggarwal
Orissa: Thelma Narayan
Chair: P.M. Kulkami

Leela Visaria to facilitate

Chair: R.N.Gupta

Leela Visaria

Chairperson & Discussant:
H Sudarshan

Chairperson & Discussant:
Bela Ganatra

4.00-4.30
4.30-5.30
5.30-6.00

BREAK________________________
Qualitative Studies - Presentations 1,2
(Anjali Radkar, CHRP)____________
Discussion

Chairperson & Discussant:
Renu Khanna

24th May 2003

9.3010.30
10.3011.00
11.0011.30
11.30 to
12.30
12.301.00
1.00-2.00
2.00-3.00
3.00-3.30
3.30- 4.30
4.30-5.30

Presentations 3,4
(Anandhi, RUWSEC)
Discussion

Chairperson & Discussant:
Sudarshan Iyengar

BREAK
Presentations 5,6 (ANS,MIDS)

Chairperson & Discussant: PM
Kulkami

Discussion
Lunch__________________________
Presentations 7 and 8 (GIDR, FRHS)
Discussion_______________________
Key issues emerging from the studies analysis for synthesis report_________
Overview suggestions______________
Time line for final reports

Chairperson & Discussant:
Dinesh Agarwal________
Facilitator: Vimala
Ramachandran

Note:
1. Each presenter for mulitcentric studies and informal providers studies gets 15 -20
minutes
2. Each presenter for Community based studies & Qualitative Studies gets 30 minutes

Vo W <?>-

EXECUTIVE SUMMARY-- Dr Mala Ramanathan
Introduction

As a public health issue unsafe abortion invites attention of the researchers
i^is^X'0 1 e® health(sect0.r' To reduce the adverse effect of the unsafe abortion
J is also necessary to understand the issues related service provisions There
have been very few studies on abortion in Kerala and even less from a providers'
nnrJnnr 'Ve' The ?Udy formed Part of a multi-centric intiative to study provider
perspectives in abortion in six states to India under the agois of 11^ Abortion

aSr(rc,EHAT)'nMdumb:Lrd'na,ed by Cen,re ,Or Enqui,y int0 Heal,h a"a
Objectives

LfLSm^UdyfiS an att6mpt t0 futfil fhis 9ap in abortion research in Kerala bv
attempting to assess and analyse abortion services in Kerala from a providers’
perspective, incfuding organisation, management, Sties technXv

registration, training certification and utilisation in the public and private sector
Methodology

These “tXVdS'S' Sl'r,°y

Carr’ed 0U, ln lw° d's,ricls slale duri"0 20“1 -2

schedule for the 85 amStor's ThSsS^als^ eJploresTh^St^

services and to identify problems related to abortion services.

q C

Salient Findings

The mechanisms for monitoring MTP services in thP ctato

x

vii

Some ol the administrators were not aware of the requirements of site
registration for the provision of MTP. Registration of MTP centres is not an issue
of serious concern for the District Medical Officer who has been entrusted with
the authority to register or de-register institutions within the district. The private
facilities do not experience any urgency to obtain registration from the
government. This could be because of the non-implementation of state
regulatory mechanisms that seem to follow a laissez faire policy in this regard as
long as there are no serious public health threats that result.

However, a majority of the providers working in both public and the private sector
were well qualified irrespective of the site certification. Religious beliefs restrict
some providers and administrators from applying registration. This is more visible
in the northern parts of Kerala. However services are being provided in these
institutions with appropriately trained providers as it is remunerative.
Consent from both the woman and her husband or any other close relative is
necessary for most providers as this providers them with legal and social
protection. Most institutions obtain written consent before performinq the
procedure.

Private sector institutions provide for auditory and visual privacy compared to
public sector. As a result most of the women in the community prefer the private
sector even if government facilities are available free of charge. Clean toilets with
running water and well furnished waiting area result in the clients perceiving the
quality of services to be better in the private sector. But in the government
hospitals tnese facilities are not available in many places and even if it is
available proper maintenance is lacking.

The necessary equipments are available in the health institutions irrespective of
e site registration. Private sector gives prompt maintenance for the damage of
instruments compared to the public institution. Most of the private institutions
keep the necessary drugs in their institutions. However, contraceptive
commodities were more likely to be available in the public sector institutions. The
providers working in public sector were also more likely to be trained in
reproductive health and rights and universal precautions.
The informal providers were invisible and the researchers could not identify any
who were willing to participate in the study. All the providers who participated in
the study had basic medical qualification and majority of them had postgraduate
qualifications. Such providers were more likely to be found in the public sector.
I he public sector also had better qualified nursing staff.
There exist no adequate disposal mechanism in both the public and private
institutions. Many institutions using open pit garbage disposal and burying
mechanism for waste disposal. Only very few institutions has access to

viii
X

incinerators. Half of the private health institutions and one third of the public
health institutions mentioned that they bum syringes and gloves.

Accessibility of services is very good in all the institutions and most of the
hospitals were within a kilometre distance from public transport. The cost of
abortion services varies by institution and duration of gestation in the private
sector, but in public it is said to be completely free of charge. The highest number
of abortions provided per month was in tertiary care public health institutions. All
the providers in the study were able to communicate in the local language and a
majority were women.

The private health institutions benefit from the lucrative practice of selective first
trimester abortions but do not take on the burden and the associated insurance
and legal costs of more difficult second trimester abortions allowed by the law.
The high-risk cases are often handled by the public sector causing them a double
burden as they have the mandate to take on the provision of services that are
legally mandated and also that which are more difficult.
Some case studies were conducted to understand the dynamics of quality of
services in both public and private health institutions. A summary composite
index was construct to understand the overall quality of services in the selected
institutions. On the whole the quality of services were found to be better in the
private sector. In the first district there was a sense of openness whereas in the
second district a sense of secrecy surrounding the provision of abortion.

Conclusions
The process of site registration needs to be streamlined in Kerala making it more
transparent. The quality of infrastructure and equipments were better in the
private sector and so was the maintenance. However the training and skills of
staff in the public sector were better. There is a need to improve the services in
the public sector by staggering the work at the tertiary care through mechanisms
of referral from lower level public sector institutions and equipping these with the
infrastructure and staff to deal with first trimester abortions. Such initiatives could
be funded through the RCH programme or managed by the local selfgovernments which can decide on the mechanisms of subsidisinq these
necessary reproductive health services.

ix
X

EXECUTIVE SUMMARY
Introduction
A study titled “Situational Analysis of MTP Services in Kerala: Provider
Perspectives ” was undertaken to understand the process, facilities technology,
registration and training of MTP services in Kerala. To expand this analysis
further, the study was extended to include the community’s perceptions of the
MTP facilities in their midst. This qualitative study was designed as
supplementary part of the early mentioned quantitative study.

Objectives and methodology
The objectives of the study are to examine the community perspectives of
abortion, its legal status, and the available abortion providing centres in Kerala.

Focus group discussion was used to obtain these perceptions from the
community. Two districts, Kollam and Malappuram, in Kerala were selected to
conduct the FGDs.

Findings
Women experienced many reproductive health problems for which they sought
health care in both the private and the public sector. Morbidity experiences of
women varied by age and older women were more likely to report some
menopause related symptoms and younger women report needs related to
pregnancy and childbirth.
In Kollam district where public facilities were better functioning, women preferred
them. In Malappuram this was not so and the private sector was more often
sought and utililsed. In Kollam and sometimes in Malappuram women used a mix
of public and private for reproductive health care, especially pregnancy and child
birth related needs.
Women felt that the conditions prevailing in govt hospitals were inadequate.
They were not clean and the staff had to be paid for services and supplies that
had to be used for the procedures bought from outside and drugs were often not
available and had to also be bought. The absence of a woman doctor in the govt
facility also seriously restricted the type of health care sought at the facility.

In spite of these limitations many women felt that the govt services were safer
than the private sector where the profit motive was suspected to lead to possible
unscrupulous practices. Other women said that the staff in the govt, facilities
were not polite. On the other hand though the private institutions were expensive

. 5
X

but the staff were polite. In Malappuram the private sector was more utilised but
this was because there were more likely to be functioning and well equiped
private facilities than the public facilities.

Women were aware of specific abortion services in their neighbourhood. In
Kollam, abortion services were few but available in both the public and the
private sector whereas in Malappuram abortion services were almost absent in
the public sector. This resulted in more costly services in Malappuram than in
Kollam. Further in Malappuram the need for confidential services was more
severely felt.
In the public sector supplies had to be bought and many of the staff paid, it
added an additional burden to the already difficult decision of abortion. While in
the private sector it was costly in both Malappuram and Kollam, nowhere was it
actually free.

7 here was serious stigma attached to undergoing abortion for both married and
for single women. In Malappuram both men and women were not aware that
abortions in many circumstances were legal. This meant that they looked upon
abortion as a favour not a right in health facilities.
Conclusions

In Kerala there is stigma attached to abortion and some men and women believe
it is illegal. Women were aware that the pubic sector discourages the use of
abortion. The public sector’s reluctance could stem from the need to cater to
more essential services like pregnancy and delivery and they may therefore view
abortion services as an optional that can be avoided in situations of over
crowding. Further the lack of supplies and drugs make it all the more difficult to
provide this service. It is in these circumstances that the private sector steps in
to provide confidential services that respect the women's need for privacy as
abortion is stigmatised in the society and if women and their families are not able
to meet the costs involved they chose to have the child instead.
Public sector services need to be enhanced to improve the supplies and special
efforts have to be made in Malappuram district to ensure that functional
reproductive health services are available at public sector institutions. Since
there is a stigma attached to undergoing abortion, but women recognise that
there are mitigating circumstances under which abortion can be allowed,
advocacy efforts are needed to emphasise its legal status.

6

X

Situation Analysis of MTP Facilities in Haryana
Executive Summary - CORT

In view of the millions of abortions being performed in places and by persons other than
those registered for providing abortion under the Medical Termination of Pregnancy MTP)
Act of 1971, recently, the National Abortion Assessment Project undertook the challenging
task of assessing and analysing abortion services in the public and piivate sector in si> states
of India namely Madhya Pradesh, Haryana, Kerala, Rajasthan, Orissa and Mizorai i. The
present study was conducted in Haryana by Society for Operations Research and frainii.g
The study attempted to understand the situational analysis of MTP services in both
public and private sectors in two districts of Haryana. As per the available service statistics,
the number of MTP cases in the state of Haryana, has increased from 225 in 1972-73 to
22,751 in 1996-97. During the year 1994-95, the highest number of MTP (23,700 cases) was
recorded. Similarly, the number of registered MTP facilities, which was 25 in 1974-75, has
increased almost eight times to 228 in 1996-97. In terms of caseload per clinic, the data show
that in 1972-73, on an average, 9 cases were reported by each clinic and this figure had gone
up to 100 MTP cases per clinic in the year 1996-97.

As the present study was a part of a multi-centric study, a uniform methodology was
adopted for all study sites. The method of data collection was mainly quantitative in nature,
however qualitative data was also collected For this purpose both structured and unstructured

guidelines were used to collect data.
The present study was carried out in two districts of Haryana state viz. Jind^and
Yamunanagar. The criteria for the selection of these districts was based on their ranking in
terins^fwomen’s health indicators. On the basis of the aggregate of all the identified six
women's health indicators1, the best performing district and the least developed district were
identified. However for the purpose of this study, the second best district (Yamunanagar) and
the second worst district (Jind) were selected to avoid the extreme typical districts.

Sampling

Within each district, three blocks were
selected. The criteria for the selection of the
blocks was the percentage of urbanization
(highest, average and lowest percentage of
urbanization) in the district. Within each
identified block, all government facilities
upto the PHC level were visited and those
providing
abortion
services
were
interviewed, and interviewed in case they
were providing abortion services. For
identification and selection of private
clinics, a list of all the private institutions in

Coverage
Jind

Public
Total identified
Agreed to participate
Interviewed______
Private
Total identified
Agreed to participate
Interviewed_______

Yamuna All
-nagar
___

2
2
2

6
6
6

8
8
8

32
22
16

55
43
32

87
65
48

450
221

300
158

750
379

Informal provider

Total listed
In tend owed

1 The indicators were: Sex Ratio, % of institutional deliveries, female infant mortality rate (1MR). Contraceptive
Prevalence Rate, (CPR), Total Fertility Rate (TFR), female literacy rate
1

all the urban areas and major villages of the selected blocks was prepared. Pro\ iders of
abortion services were identified and interviewed with their consent. In addition o these
formal providers, in the major villages (PHC, sub-centre villages) in the rural areas, an
attempt was made to identify the informal providers, who provide services to t ic rural
women. Those consented to participate in the study were interviewed
It may be mentioned here that at the time of data collection, there were wide publicity
campaigns in the media regarding sex determination tests and the enforcement of the Prenatal
Diagnostic Techniques (Prevention of Misuse and Regulation) (PNDT) Act. Providers were
reluctant to talk about abortion and it took a lot of effort to convince them, particularly those
who were not registered, to participate in this study. '

All the identified providers were spread across 132 villages in six blocks. Among the
private clinics, 87 facilities (32 in Jind and 55 in Yamunanagar) that were currently providing
abortion services were identified. Nearly three-fourths of these private facilities (i e. 65
facilities) were ready to participate in the study, but eventually 17 refused. Finally only 55
percent of the facilities (16 facilities in Jind and 32 facilities in Yamunanagar) partic pated in
the study.
In the case of the informal providers, a listing of 450 and 300 informal providers was
done in Jind and Yamunanagar respectively. Of these, 221 providers in Jind and 158 in
Yamunanagar agreed to be interviewed.

Key Informants’ Perspectives on the Ml P Act/Rules and
Regulations
Informal discussions were conducted key informants—the Director of Health Services,
Government of Haryana, a medical officer, and three registered abortion providers who are
also members of the Federation of Obstetrician Gynaecologists of India (FOGSI) —regarding
their views on the MTP Act, its rules and regulations, interpretation and implementation, and
their suggestions for improvement in the rules and regulations to make safe abortion
accessible to women.
Findings reveal divergent views among providers and government aiuthorities
regarding MTP Act, its rules and regulation For instance, while the government authorities
insisted that spousal consent is necessary to conduct MTP, while private sector providers
opined that whoever accompanies the client can give the consent. The informants were aware
that the criteria for the training and certification of doctors in the public and the private sector
are the same. However, the process of registration is different for the public and private
facilities. In the public sector, all the health infrastructure upto the level of PHC are
recognized for providing MTP services, as they are required to have the required
infrastructure. Private clinics get their registration only after the government authorities have
visited and verified that the infrastructure and equipment in these facilities match the
government specifications.

While discussing on the formats for reporting MTP, the providers found the format
simple, but suggested that the time lag should be reduced in reporting, as well as duplicating
the information while reporting by number or by name. It is also perceived that certain
information collected in the reporting is unnecessary and is never utilized.
2

i

<4

In order to encourage registration as MTP centres by the private sector, the Director
of Health Services suggested.

Awareness among the providers should he given that there are tto problems in getting
the clinic 6r hospital registered under the MTP Act. They should be explained^ that it
is a very easy procedure. They must be told that they will be protected /torn the
criminal proceedings if they get their clinic hospital registered.

In the discussions with the private sector providers it was apparent getting a facility
registered was not at all difficult, contrary to the general belief that private facilities face a lot
of bureaucratic hurdles that discourage them from applying for registration.

I

Regarding the steps to simplify the MTP registration, certification and reporting
procedures to increase access to safe abortion services, two of the key informants — the
Director of Health Services and one of the providers felt the current procedures were already
simple enough and did not require any modifications.
It is already very simple, as 1 already mentioned that it is now decentralized. ! don 'I
think it is not simple.

This could be the case as copies of the government circular dated 23rd March, 1989,
memo no. 1/20/88-1HB-1I were sent from the Commissioner and Secretary of Health,
Government of Haryana to all the Chief Medical Officers in Haryana State The memo
clearly states that to expedite action on the applications seeking approval of place otl er than
government institutions tor conducting M I P. it has been decided to delegate the po vers to
the Chief Medical Officers.

Findings from the Facility Survey
The following section presents the major findings from the facility survey. The discussion of
the findings has been done in percentages occasionally. However, this should be interpreted
cautiously, as the base is small.

Certification
In Haryana, apparently the processing of papers for certification ot lacilities is not a problem
Time required for this varied from 20 days to two months. Yet. only nine facilities out of the
total 48 had both, the place and a certified doctor. In sixteen facilities, a certified provider
was available. The certification of five clinics was in process. Probing into the reason for not
registering the clinic revealed that it was mainly because the providers had never perceived
the need for it nor never thought about it.
Except for one private clinic, all the registered clinics mentioned that they were
reporting the MTP cases. In most of the clinics, the consent form was not available. Among
the certified facilities, providers maintained the consent either in the register or in the form.

3

Infrastructure
Most of the facilities (both public and private) were maintaining privacy and comfort of the
clients. Auditory and visual privacy were maintained. The condition of the procedure room
was good, it was clean in all the facilities, as the room was dust free, floor was clean and the
operation table was in good condition. In all the public facilities, indoor ward was used as a
recovery room for abortion clients, whereas some of the private clinics were also using other
rooms as recovery.

Equipment and Supplies

Analysis of data on equipment and supplies indicates that most of the facilities have reported
the presence of ilecessary equipment to conduct the abortion. Private certified clinics were
relatively better equipped as compared to public facilities. Complete sets of D and C and
EVA were more than MV A equipments. Sixteen facilities had in-house ultrasound facility.

Analysis of data on sterilization equipments reveals that most of the certified facilities
had autoclave drum and steam sterilizers, but in case of Formalin chamber, more (7 certified)
private clinics out of total nine clinics were equipped, as compared to only three public
facilities out of eight. It is encouraging to note that except for five uncertified clinics all the
clinics had at least one source for preventing infection.
Manpower
Availability of type of providers in the clinics reveals that 40 percent (22 facilities) of the
facilities had at least one full time gynaecologist, 17 clinics had a full time MBBS doctors
and the remaining 20 clinics were manned by BAMS doctors. More certified facilities
compared with those that had no certification had a full time gynaecologist. The latter were
staffed mainly by BAMS providers.

All the facilities either did not have an anaesthetist or had an arrangement w th one.
Among the private facilities, only one clinic had a full lime anaesthetist. In 23 facilities they
were available on call. With regard to the availability of support staff', data reveals that all
public and private certified hospitals/clinics had at least one nurse. Non-availability of a nurse
was observed in one-fifth of the uncertified clinics
Emergency Services

Nearly two-thirds of the facilities reported that they had the arrangement of having a doctor
present in the night, to attend to the emergency cases related to abortion complications, while
15 percent of the clinics were staffed by a nurse alone, to attend to such cases. The remaining
one-fifth of the clinics did not provide any service in the night. Although a good proportion
(85 percent) of clinics/ hospitals had facilities for overnight stay.
More than half (58 percent) of the clinics had postponed the services at least once
during the last three months basically, because the provider was not available (82 percent).

•4

Characteristic of Formal Providers

Majority of the facilities covered in this survey were
manned by a female provider.
Providers were
interviewed because they provided MTP services,
but all of them were not formally trained in
conducting MTP.

Characteristics of Provider
(N=57)
No. of female prox ider
Ax erage age (in years)
Private facility

Formally trained for MTP

4X

39.2
49
33
20
13
24

Formally trained doctors other than the
Gynaecologist
Gynaecologists had undergone MTP training either
MBBS
at a teaching college or a district hospital. MTP No formal training for MTP
methods in which most of the doctors received Avg. years of providing abortion
9.9
training, included D&C, MVA, and D&E and they services
were confident in providing these procedures. D&C
was the most common method in which doctors had hands-on training. Three doctors in the
certified clinics were also doing 2nd trimester abortion using MTP techniques like, extra
amniotic and intra amniotic methods.
Abortion Services

Most of the facilities (82 percent) were providing abortion services only upto first trimester
pregnancy (12 ^weeks), while three public facilities and three uncertified private facilities
provided MTP services even above 12 weeks of gestation.

The mean number of abortion cases per clinic reported for the last 3 mdnths was
relatively higher in private certified facilities (51 cases), followed by public hospitals (33.9
cases) and uncertified private clinics (1 1.0 cases). One hospital reported having handled two
cases of miscarriage (of pregnancies upto 20 weeks gestation) during the last 3 months. There
were three private unregistered clinics, staffed by an obstetrician & gynaecologist who
provided abortion services up to 20 weeks of pregnancy. District wise analysis of|the same
data for private certified and public hospital shows a different picture. In Jind d strict the
mean number of abortion cases per month, was more than double of that in Yarrunanagar
district (22.8 and 9.3 cases per month per clinic respectively). This could possibly be due to
the high number of abortion cases reported by the district hospital in Jind.
Medical Standards
Data on technique used for abortion indicates that in the early stage of the first trimester,
MVA was preferred by the formally trained doctors to perform the abortion, while in the later
stages of the first trimester D&E was the common method used by the formally trained
providers to terminate the pregnancy. On the other hand in the first trimester of pregnancy
D& C was used by most of the providers who had no formal training. About one-fourth of the
total providers also mentioned use of drugs or medication for abortion of pregnancies up to
the eight weeks of gestation. For termination in the advanced stage of gestation, i.e., more
than 12 weeks of pregnancy, only 5 doctors were engaged in providing the abortion services
during the last three months. For this, they mentioned the use of extra-amniotic method.
Similarly, data on pain control methods or anaesthesia used for the different stages of
gestation as collected from the providers indicates that most of the doctors (77 percent) were
usin£analgesia/sedation for pain control up to 8 weeks of gestation It was surprising to note
5

i

that more than one-fourth providers were also giving general anaesthesia in the same period,
which is generally used for MTP procedures conducted in the later weeks of gestation.
Analysis of the data further shows that only 7 doctors were providing the abortion services
beyond the first trimester. Among them 6 providers gave analgesia/sedation for pain control
in the second trimester, while local or general anaesthesia was reported by three providers.
Cost of Abortion

Data on cost of availing MTP services indicates that the cost of MTP services is, directly
related to the period of gestation. Though the amount varied widely for the same gestation,
the average minimum cost in the private clinics for different periods of gestation were Rs.j03
for up to 12 weeks and Rs. 660 for the period of 13 to 20 weeks of gestation. The: average
maximum cost was Rs. 424 for up to 12 weeks and Rs. 773 tor abortion above 12 weeks of
gestation. In the public sector except in one hospital, all the facilities w'ere offering;services
either free of cost or on a nominal charge.

Post Abortion Complication
On an average 5.1 women with post abortion complications were received by the clii ic in the
last three months. Most of the providers reported that they received cases of incomplete
abortion (80 percent), followed by pelvic inflammatory disease (60 percent). Woi len with
other complications like haemorrhage, septicaemia, perforation and shock were also reported
by less than half of the providers. The above data does indicate that woman arc experiencing
post-abortion complications which should be negligible, il they had undergone M I P in a safe
and hygienic environment and conducted by a trained provider

Counselling
Majority of the providers (81 percent) reported that they discussed complications in the pre
counselling session and medication during the post abortion counselling. Analysis of data
indicates that more than half of the doctors in both the categories also discussed about the
sexual intercourse. Probing on the advice given for follow up visits shows that women were
advised by all the providers for a routine check up.
Contraceptive Counselling

Except for one provider, all the doctors reported that they were oHering cont.aceptive
counselling to abortion clients. Most of the doctors insisted the use of modern spacing
methods. The methods doctor insisted on included IUD (84 percent), followed by pills (77
percent) and condom (60 percent). The most popular method among the clients was IUD
followed by pills, condom, tubectomy, injectables and vasectomy as reported by doctors.
However among the informally trained doctors pills, ranked at the top followed by tUD as a
choice of contraception among the clients.

Infection Prevention
Half of the hospitals/ clinics dispose off the products of conception by burying and cover it,
while burning of gloves and syringes was reported by more than one-third of the respondents.

z
6

Referral Patterns
A little more than half of the providers were referring at least some of the clients to other
hospitals. Generally, women who had signs of medical risk (82 percent) and gestation weeks
above 12 (75 percent) were referred by the providers. District hospital was the most pommon
place reported for referral among the doctors, followed by private hospital and medical
college.

This indicates that though services may be sought in any clinic, for any complicated
or difficult case both the providers and the clients depend on the services of the district
hospital / medical college. Some providers also revealed that they did not force the clients
where to go and left it to them to decide the facility of their choice.
Further analysis of the data shows that out of total facilities, only eight clinics
reported of referral arrangement with another hospital, wherein patients can get treatment on
priority and are reverted back after getting the required care.
Circumstances when Abortion Services Provided by the Facilities

. .

J

Except six uncertified clinics all the facilities were not providing the abortion services to a
woman if she comes alone to the facility to seek abortion services. Further analysis of data
reveals that slightly more than two-thirds of the facilities were ready to offer abortion
services in at least one of the following circumstances: women comes with friend, but
without family member, unmarried woman, widow/separated/ deserted, and married but has
no children.

Informal Provider
Profile of Informal Provider

The mean age of informal provider was around
(Perce n la gc)
40 years. Gender wise break-up shows that about
N T79
Cha raetcristics
39.7 ~
three out of four informal providers were males, i
while 25 percent in Yamunanagar were females; Sex
12.9
in Jind 96 percent of the informal providers were s Male
87.1
• Female_____________________
males. This scenario is quite in contrast to the
Education
gender wise distribution of the formal providers.
9.2
Illiterate
1.9
Majority (72 percent) of the providers were Below high school
72.0
High
school
educated upto high school. Only 17 percent of
16.9
Graduate and above__________
them had studied upto graduation or more.
Type of provider
Majority (69 percent) of the informal providers
2.9
ANM/nursc
belongs to the village practitioner/RMP category.
69.4
RMP/village practitioner
Dai

I 1.1

15.8
Doctor (BAMS/GAMS)
About two-thirds (67 percent) of informal
Others_____________________
()
1_
providers (more male (68 percent) than female
'13.4
Mean years ofproviding services
(57 percent), admitted that they were contacted
by women for the treatment of delayed
menstruation. The providers treated this problem mainly using concoctions (77 percent),
followed by abdominal massage/pressure (67 percent) and giving tablets (33 percent). None
of the providers mentioned use of any instrument for invasive method The informal
providers mentioned that to a large extent treatment using these methods, particularly
concoctions and injections were successful

7

In case the use of herbs/concoction was not successful, the next course of action taken by 45
percent of the informal providers included provision of tablets or injection, while the rest
refer the client to the city. Similarly, 58 percent of the informal providers use injection as a
last option in case of failure of tablets. After injecting injection, if it docs not work then they
just refer to the city.

According to the informal providers on an average 5 women per month contact to
them for the treatment of delayed period. The minimum average cost incurred by th'<e client
was Rs. 82.3 and Rs. 133 was the maximum cost for treatment of delayed period.
On an average, 4 cases per month of post abortion complications are received by the
informal providers. The main reasons for such complications reported by them were
weakness (21 percent), incomplete abortion (20 percent) , weaken uterus (18 percent), due to
more weight (17 percent) and abdominal pain.

More than two-thirds of the informal providers did not approve of abortion, while 15
percent approved of it conditionally. The knowledge about the legality of abortion is very
poor among the informal providers. Only 13 percent of the informal providers reported that
abortion is legal while majority (85 percent) of them said it is illegal.

s

INVESTIGATION

SEX SELECTION

THE GENDER

ESTAPO
by Anna M.M. VETTICAD with
Ramesh VINAYAK

OCTOR
SAAB,
we’ve been married
six years a n d h ave a
five-year-old
daughter. We want
a second child now, but only if
1 it's a boy. Can you help us?” It’s
|1 a hesitant question.
The bearded man across
the table from us, Dr Sanjay
Vi Gupta of Chandigarh’s SanIj tokh Nursing Home, has
jr no time for pointless pleat ■»/ santries. “How many aborlions have you had?” he
PTz asks. "None. We've been using birth control. We won’t risk
( another girl, so when we heard
about your ad for XY separation,
we decided to come to you.”
If apprehension shows on our
faces, hopefully he inter­
prets it as the despe­
ration of a married
couple without a

A controversial
sex-selection
procedure widely
available in India
skirts the law am
prevents the very
conception of
female babies

son: a couple who, so we inform him.
have travelled all the way from
Ludhiana to Chandigarh in search of
the nirvana he offers: a controversial
technique which promises the concep­
tion of a male child.
The truth is that we are journalists
posing as husband and wife, here to
track Punjab's baby boy boom, drawn by
murmurs that clinics in the state con­
tinue to stray into a legal grey area with
pre-conception sex selection. In this fer­
tile agricultural region, the term "infer­
tility treatment”, as in the case of
Santokh, is often a sobriquet for XY sep­
aration. techniques in which X and Y
chromosome bearing sperms are sepa­
rated and the Y-chromosome-bearing
sperms used to fertilise the female egg to
ensure the conception of a male embryo.
Sex determination after conception
through ultrasonography, amniocente­
sis and other techniques is already ille­
gal under the Pre-Natal Diagnostic
Techniques (pndt) Act. but sex selection
before conception falls in a legal no­
man’s land. Two months have passed
since the Supreme Court, ruling on a
writ petition, slammed the Centre and
states for npn-implementation of the
Act, and suggested that it be amended
to keep pace with technology (see
boxes). Next month the court will assess
subsequent action taken. The Govern­
ment is even now working on amend­
ing the Act and banning XY separation.
Dr Gupta, of course, is not. bothered.
Graphics by YOGESH CHAUDHARY

SIFTING OUT THE GIRLS
A sperm has X or Y chromosome,
the egg X chromosome. Their
combination
decides gen­
der: XYfor
boys, XX for
ERICSSON’S
girls.
I

METHOD:

Centrifuge
Illustration by NILANJAN DAS

54

INDIA TODAY ♦ JULY 16.2001

Y A semen
sample is di­
luted. It is then
centrifuged.

k

CARE TODAY
REBUILDING GUJARAT

COLLECTIVE EFFORT

"W

•j

We are happy to report the enthusiastic response of our readers to India today’s appeal to
contribute to the "Rebuilding Gujarat” fund, set up to help those shattered by the earthquake that
devastated Gujarat on January 26. 2001. Contributions of Rs 5.000 or more are listed below:

7.000
Rs
Rs 5.000 Jatinder Kaw
Lt-Colonel Surender Kumar
Rs 6,260
Rs 5.000 Paras Electronics, Hyderabad, and its staff
Alka Ghanekar
5,100
Rs
S.C. Grover
Officers, jcos and other ranks of the
Rs 1 7,000
Rs 12,000 Compassion Unlimited, Singapore
307 Medium Regiment
5,227
Rs
Rs 5,000 Shibber Saraf Ali
Loveleen Kaur Brar
Rs 50,000
Rs 5,000 K.D. Ilanda
G. Meenakshi
5,000
Rs
Rs 5,000 Srinivasa Rao Trinetram and family
M. Ganesan
Rs 1 1.100
Rs 5,000 Dr R.V. Sagar and family
Rajkumar Kasara
5,100
Rs
Rs 5,000 I larjit Singh Sandhu
Hans Kumar Jain
Rs 82,556
Rs 1,64,675 Chandiran Francois and friends
Tommy Hilfiger (India) Ltd
Rs 31,495
Rs 11,000 Sanjeev and Sunil Jindal
Colonel P.K. Chaudhary
5,250
Rs
Rs 5,000 Rajneesh Jaiswal
L. L. Bhandari
10,000
Rs
Perfect
Machining
Centre
Rs 20,000
S.K. Aggarwal
5,000
Rs
Rs 40,000 Parvathi Sivachanemougam of Paris
Hamdard National Foundation (India)
5,000
Rs
Nandan
and
Arohi
A.
Pathak
Rs 5,000
Lt-Colonel Harbans Singh
Rs
7,000
Rs 5,000 DrV. Radhakrishnan
Colonel K.P. Singh
5,000
Rs
B.M.
Das
Agarwal
Rs 5,000
Baby Aastha
5,000
Rs
Rs 5,000 K.S. Chittyana
Master Apurav
5,001
Rs
Savitri
Convent
Balika
High
School
Rs 5,555
Ganesh Nilangekar
Rs 32,000
Rs 15,000 Members, Lions Club. Kasganj
Moneeta and Rohit Kaila
Rs 10.000
Rs 5.000 Anonymous
Mrs and Mr Jayachandran
5.000
Rs
A.
K.
Srivastava
Rs
5,000
Gayathri S.
5,000
Rs
Lalita
Lagu
Rs 5.()()()
Chandar Tiwari
63,600
Rs
Staff
of
FSD
International
Pvt
Ltd
Rs
10,000
M. P. Mohan
Rs
5,000
Rs 10,000 Falguni Patel, FDS International Pvt Ltd
Harsha Exports
10,000
Rs
Lt-Colonel
(retd)
V.R.
Deshpande
Rs
5,000
E-Pac Technologies Pvt Ltd
Rs 5,000 Employees of Magnum Technology
Dr Parvin S. Vare
Rs 6,000
Rs 5,000 Solutions Pvt Ltd
Usha and Ramcsh Chand Gupta
Rs 6,000
Rs 70.550 Magnum Technology Solutions Pvt Ltd
Dr Santanu Das, CEO, Transwitch India
Rs 6,000
Employees, Magnum Solutions Pvt Ltd
Shri Saddaram Rustagi Public
Rs 6,000
Rs 5,000 Magnum Solutions Pvt Ltd
Charitable Trust
Rs 13,274
Rs 5,000 Employees of World Media Ltd
Armour Finance & Commerce Ltd
13,274
Rs
World
Media
Ltd
Rs 5,000
Armour Software Tech Pvt Ltd
Rs2,49,997
Employees
of
Living
Media
India
Ltd
5,000
Rs
Y.K. Jajoo
Staff and students of Dr G.H. Singhania
Staff and nursing students of Fatima
8,016
Institute of Management & Research, Kanpur Rs
Rs
50,001
Hospital. Lucknow
Rs
9,400
Bharat
Shell
Ltd,
Kheda
Plant
Rs 6,959
Staff and students, DPS, Jodhpur
5,000
Rs
Rs 10,000 Ashok Bhandari
Indumati R.V. Singh
5,000
Rs
Rs 10.000 Dr D. Tandon
B.V. Rajan
Rs
5,000
S.
Kailwoo
Rs
30,600
Retired railway employees, Bhilai Charoda
Rs 1 1,000
Rs 5,000 Bhuvan Dwivedi
Shashi B. Kapoor
5,000
Rs
Rs 5.000 Professor S.R.V. Rao
Brigadier (retd) EEC. Bulsara
Rs 10,000
Rs 5.000 R Shiv Kumari Devi Trust, Shohratgarh
V.N. Das
Rs 7,85,000
Xerox Modicorp Ltd
Management, staff and students of Green
Rs 11,54,750
Rs 15,000 The Xerox Foundation
Lawn Academy
Rs 1 8,669
Rs 17.000 Employees, F1L Industries Ltd
Dhirendra Kumar Tiwari
7.444
Rs
K.K.
Bhat,
F1L
Industries
Ltd
Teachers and students, Happy Hours School Rs 2 3,460
5,000
Rs
Rs 5,000 Ajay Sahni
Y.P.S. Rana, advocate
5,000
Rs
Bhavdeep
Singh
Sawhney
and
family
Rs 5,000
B. C. Gupta
Rs 20,000
Rs 11,000 Anchor Fincap Pvt Ltd
Behariji Charity Trust
5.000
Rs
Rs 10.000 Gravure Arts
Savita Chandrakant Rathi
Rs 20,750
Rs 5.000 St Joseph's School. Riband Nagar
Sandeep P. Chaudhari
Rs 63,257
Rs 92.000 Students, UM Lucknow
Seth Anandram Jaipuria School
5,001
Rs
Vijayalaxmi Singh
Students, NBKR Institute of
10,000
Rs
B.
L.
Loomba
Rs 42,001
Science & Technology
Rs 60,613
Rs 10,600 Givaudan (India) Ltd
LMW Unit II workers
5,001
Rs
Saneh
Deep
Chopra
Rs 10,000
Ajit Ramanlal Choksi
5,000
Rs
Rs 15,000 Kids Chaman
Himanshu Ajit Choksi
10,000
Rs
Harish
Dayani
Rs 10,000
C. S. Chandrasekaran
JULY !(■ 2001 ♦ INDIA TODAY

53

“The Government has brought in a
new law called the PNDT Act, which has
made all this illegal." he volunteers.
“But you don't worry. Nothing will hap­
pen ..." Gupta goes on to explain the
technique involved in XY separation,
even drawing a crude sketch, and
claiming a 90 per cent success rate. He
also suggests an alternative requiring
the use of a chemical by the female part­
ner to slow down or kill off X-chromosome-bearing sperms during sexual
intercourse. Further reassurance from
the good doctor: “If you conceive a girl,
you could always have an abortion. 1
don’t have an ultrasound machine, but
there are plenty of places close by that I
could send you to, who will tell you the
sex of the child. Because of the law. they
won't write it down, but they'll tell you
verbally if it’s good news or bad news."
It's as simple as that. Not only are
techniques such as XY separation on of­
fer. ultrasound clinics across the coun­
try continue to defy the existing law by
revealing the sex of the unborn child to
parents. If any further explanation was
needed for the skewed child sex ratios
(in the 0-6 age group) shown by this
year’s provisional Census figures, it is
this: that pre-conception sex selection is
compounding the disastrous effects of
continuing female infanticide and foeti­
cide. Funjab. the worst of the states,
had only 875 baby girls for every 1,000
boys in 1991: now it has just 79 3.
At Deep Hospital in Ludhiana, the
board outside Dr S.P.S. Virk’s office
proudly displays an advertorial in The In­
dian Express listing the facilities available
at Virk Infertility Research Centre here at
Deep and at his Bombay Infertility Re­
search Centre in Virk Hospital. Jaland­
har. “pre-selection procedures by XY
sperm separation "among them. The ad­
vertorial carefully justifies the use of the
technique with the remark: "... definite
medical indications ... exist where sexlinked genetic diseases make it desirable
to have a healthy child of a particular
sex only". That was an objective of the

RAJESH BHAMBIi

CF
i

i i

]■ ■ K
*

A

Dr Sumeet Sofat MD

J

L

MINDLESS MEDICOS: Drs Sumeet and Sumita Sofat carry out XY separation

T.S. BEDI

I

I

111 ~.l JBBBB

I.

I

SRNTOKH NCPSIHfa Htf '

Hl

j
• SEMEN BANK
’ ALL HORMONAL TESTS

6

W

Dr SUSH1L K. CHOPRA

I..

PHWl-Wgft
RAJESH BHAMBI

It
J

2. X and Y-bearing sperms
are separated when placed in
a chemical solution. The
faster-moving Y-sperms pen­
etrate the solution s denser
bottom layers, which are col­
lected and centrifuged. The
process is repeated.

3. The Y concentrate is collected
for artificial insemination. This
method is said to have a success
rate of about 70 percent.

PRE-IMPLANTATIONAL GENETIC DIAGNOSIS:
Eggs
^’~l
Sperm

2. Male/female embryos are identi,iei1 unt,er a sPecial microscope.

Male embryo

I
1. This complex proce­
dure is cited in the
Supreme Court petition.
Here, eggs are fertilised
in a petridish.

’i;?„ - a •

EML

1
Uterus

\ Female
\ embryo

3. The female embryos are
discarded. Male embryos are
implanted in the uterus.
IITY 16.’()01 ♦ INDIA TODAY

55

■ INVESTIGATION

E

G

U S

BBr e

I

HOLY ORDERS
TT'S good news and bad news rolled in
.Lone. Alarmed at falling female num­
bers, anxious activists are now roping in
religious leaders to take up the cause of
the girl child. The most significant de­
velopment came this April when an
edict from the Akai Takht called for the
excommunication of any Sikh in­
dulging in female foeticide. And the In­
dian Medical Association. Unicef and
the National Commission for Women re­
cently called a meeting of leaders of all
faiths in Delhi to condemn the practice.
But where religion goes, controversy
rarely stays away. At one point, the con­
ference was reduced to an anti-abortion
tirade. One speaker blamed the present
crisis on decades of eating eggs. Sparks
flew when Union hrd Minister Murli
Manohar Joshi, also present, called for a
re-interpretation of the scriptures. "We
need to remove everything outdated
from our religious texts. For instance, if
any scripture denies women an equal
share of property, it should be changed,"

licl;ilerl()ldi\i)i.\ roDAY.TheiiSwamiAgnivesh of llie Arya Samaj spoke about
encouraging
widow re-marriage.
“There is nothing wrong with our scriptures. ’’ snapped Swami Shri Ramanandji
Maharaj of Delhi in his speech, adding,
“A widow who remarries will go to hell.
Why should she worry about ill-treat­
ment by society? She could commit Sati."
The speech ended when the Shankaracharya of Kanchi chided him on stage.
Earlier, the All India Democratic
Women’s Association circulated a letter
criticising the choice of some of the
speakers present. A.R. Nanda, secre­
tary. Department of Family Welfare,
reacts cautiously: "What matters is
that these leaders issued a statement
against female foeticide. The rest are
their individual observations." Mean­
while. the Voluntary Health Association
of Punjab is planning district-level
meetings in the state to assess whether
the Akai Takht edict has had an effect.
—Anna M.M. Vetticad

technology when it was originally
developed, but here in India, it is the de­
sire for a son not the fear of genetic dis­
orders that drives most potential parents
to these clinics. As Gupta lets on. “Of all
the people who have come to me for XY
separation, only two wanted a girl. The
other 99 per cent came for a boy."
Another clinic, another bizarre
conversation. A 10-minute drive away
from Deep, at Sofat Diagnostic Centre in
Ludhiana, Dr Sumeet Sofat keeps his
brusque queries to the bare minimum:
how many children do you have, how
many abortions so far? “All right, you'll
need to do XY separation." he says.
Charges, he reveals when pressed,
could be Rs 10,000-25,000. but he
can’t say for sure. A girl at the reception
had earlier admitted that it could even
go up to Rs 60,000.
Dr Iqbal Singh Ahuja of Ludhiana
does not even put up a pretence. Speak­
ing to India today, this tubby doctor with
an endless supply of wisecracks, admits
that he practises Ericsson's method of
XY separation, “but only on humanitar­
ian grounds". It’s a different matter al­
together that his idea of "humanitarian
grounds" includes “a couple who have
had two girls already." He adds: "Aise lo­
gon ka dard mujhse sahan nahin jata (I
can't bear to see their pain). ” Opposing a

ban on the technique, Ahuja suggests in­
stead that select professionals should be
allowed to practise it under the constant
watch of a regulatory authority.
Incidentally, US-based scientist
Ronald J. Ericsson, who pioneered an XY
separation technique available in India,
is furious at the Government's move to
ban it. "Pre-selection of sex will dramat­
ically lower the abortion rate of female
foetuses," he argues. Pre-conception sex
selection may be just one of numerous
factors leading to a skewed sex ratio, but
it is in essence the manipulation of na­
ture with dangerous consequences, par­
ticularly in a country like India.
Forget for a moment the practice of
pre-conception sex selection. The Gov­
ernment has even failed to check fe­
male infanticide and foeticide. The
pndt Act, which came into force

“We would have
acted if any
NGO had made i
a specific
I
complaint.” ’
M. Datta Ghosh,
Dept of Family Welfare

I \ 1)1 \ TODAS ♦ JI'I.Y 16.2OO1

>

I

iq'

’

*

ACT OF FAITH: Religious
leaders at the Delhi meet
in 1996. was originally targeted at
abortions of female foetuses following
sex-determination tests. But, says
Chandigarh lawyer Veena Sharma,
“After it came into force, not a single
case has been filed in Punjab. Haryana
or Chandigarh against clinics perform­
ing these tests, though we all know it’s
happening everywhere. It’s almost a
fashion here with people scoffing at
others saying, ‘ Aapne test nahi kiija (you
haven’t done the test)?'”
“It’s so open here, we have mobile ul­
trasound vans,” says Manmohan
Sharma of the Voluntary Health Associ­
ation of Punjab (vhap). He estimates the
state has 1.500-3,000 clinics with ul­
trasound facilities. Registration of such
clinics is mandatory. But when the Court
asked states to file affidavits on action
taken under the Act, Punjab was one of
1 with
w no registered facilities.
18
Now when the Govern­
ment is on a registration
drive, there are howls of
protest from doctors in the
I state. "We object to the
I Punjab
Government’s
blanket order on registra'V f tion of all ultrasound ma­
chines after the Supreme
Court ruling, which means
even doctors using ultrasound

o
S^KARNA

56

r. L
L f ■
' E/OB

PRAMOD PUSHKARNA

“The Central
Government
k made a law
1 and just put
* it on their
bookshelves.”
Indira Jaising,
''ASBANT

Lawyer

sonography for non-genetic services
must gel themselves registered,” Dr
O.P.S. Kande of the Indian Medical Asso­
ciation in Punjab tries to rationalise the
resistance. But the point is that such fa­
cilities could be abused and registration
would help in the monitoring process.
Addressing the larger issues in­
volved. Ludhiana psychiatrist Dr Rajeev Gupta says, “The problem of
female foeticide cannot be solved unless
we tackle the dowry system and raise
the status of women. When neither the
perpetrator of the crime nor women
opting for these tests complain, how do
you prevent something happening in­
side a closed room?" Actually, vigilant
state governments could constantly
monitor clinics with ultrasound and
other facilities by routinely sending out

decoys as patients: and the Centre business,” he says.
The Court has now ordered the Gov­
should watch over the states.
But the problem goes beyond even ernment to educate the public, and to
the destruction of little baby girls. Gupta deal with clinics misusing pre-natal di­
points to the steady stream of women agnostic facilities such as ultrasound.
pouring into his clinic, traumatised by The judicial jolt seems to have shaken
repeated abortions forced on them by the government out of its slumber. Fol­
their husbands and in-laws. Ludhiana’s lowing the ruling, press ads have been is­
Sunita Shankar, 28, (not her real name) sued on the evils of sex determination.
has been suffering from severe depres­ And meetings are being held at a furious
sion for two years. She barely eats and pace, with one in Delhi just this week.
her ravaged body has been reduced to a Meenakshi Datta Ghosh, joint secretary
skeleton. She has tried to take her life (policy) in the Department of Family
twice so far. Shankar’s problem is that Welfare at the Centre, admits that her
ministry was already
having borne three
of the availabil­
daughters, she’s been
LEGAL LOOPHOLE aware
ity of pre-conception
compelled to expel six
sex-selection
tech­
female foetuses from
THE LAW: Ultrasonogra­
niques because “we’ve
her body after sex-de­
phy, amniocentesis and
been reading about it”,
termination tests, by a
other pre-natal diagnos­
but insists that this was
family longing for a
tic techniques are meant
not enough for the
son. Kamaljit Kaur
to detect various foetal
Government to act:
would empathise with
disorders. The pndt Act
“The ministry does not
her. This mother of two
bans their use for sex de­
have formal knowledge
girls has been forced to
of this fact. If even one
termination. Clinics with
undergo five abortions
ngo reported that this is
in the quest for a son.
such facilities must be
going on, with actual
The result: fits of un­
registered.
locations of clinics, ac­
consciousness and se­
THE LAXITY: Unregis­
tion would have been
vere anxiety.
tered clinics abound.
taken. But this has not
Although Punjab,
Sex-determination tests
happened. Even in the
Haryana, Chandigarh,
are rampant.
court case they’ve not
Uttar Pradesh and Ut­
THE LOOPHOLE: Pre-concited specifics.”
taranchal are de­
ception sex selection is
"That is not true,”
scribed as a Bermuda
not specified in the Act.
shoots back Sabu M.
Triangle where mil­
George, one of the peti­
Although it refers to pre­
lions of girls disappear
tioners in the apex court
without a trace, other
natal sex determination
case that brought the is­
states are far from
and “matters connected
sue into focus. "The writ
faultless. The affidavit
therewith or incidental
petition names Sofat and
filed by theTamil Nadu
thereto”, the Govern­
citart.” Besides, when
Government claimed
ment has so far opted for
Punjab’s director of
an impressive perfor­
a narrow interpretation
health services sought a
mance before the
of the law.
legal clarification in
Supreme Court: 561
THE RULING: The apex
1999, the Union Health
registration
certifi­
court has ordered strict
Ministry's casual re­
cates issued: action
sponse was that the eth­
implementation of the
taken against two es­
ical committee of the
tablishments, one be­
Act, and advised amend­
Indian Council of Med­
ing the Have A Baby
ments “keeping in mind
ical Research feels the
Clinic, also known as
emerging technologies”.
Act "relates to testing in
the Centre for Infertil­
a pregnant woman. The
ity Tests and Assisted
Reproductive Technologies (citart), question of pre-conceptual sex planning is
Madurai, offering sex selection before not covered..."
So as usual, the authorities are not
conception. “The truth, however.” says
P. Phavalam of the Campaign Against leading but being led. Fortunately, the
Sex Selective Abortion, “is that our Court seems bent on prodding somno­
complaint is caught in procedural de­ lent governments. A vhap petition
lays and no concrete action has been demanding implementation of the Act is
taken.” Meanwhile, owner P.A. Chan- pending before the Punjab and Haryana
drasekaran claims he wound up the op­ High Court. And religious leaders across
eration one-and-a-half years ago. "I India are speaking up against this social
opened this place for the good of society. malaise. For India's missing millions—
But these ladies’ organisations troubled baby girls whose lives have been snuffed
me so much, I've decided to devote my­ out—it's too late. But for the ones yet to
■
self to my father's fire extinguisher come, it's a rare ray of hope.
|ULY 16.2001 ♦ INDIA TODAY

57

LIVING

POST-RETIREMENT

The prospect of a
tranquil life near the
Ganga is drawing ever
more elderly settlers to
Hardwar and Rishikesh
■ by Shuchi SINHA

DUSTY, NARROW HIGHway wends interminably
■ ■ through teeming chaos
(trucks, handcarts and every
conceivable thing on wheels) I
■■ before you are rewarded with
a shimmering expanse of tranquil wa­
ters: the Ganga emerging from its last !
rapids in the Shivalik Hills. The road to |
Hardwar is pretty bumpy, whether the
journey is merely of the body or that of
the soul. As centres of pilgrimage, Hard­
war (literally meaning “gateway to
God’s abode”) and nearby Rishikesh
have always been thronged by those who
have done their life’s work—made their
fortune, raised their children and are left
with more memories than goals. For
when the mind is fatigued by decades of
work and the heart a little worn from
seeing children and relatives steadily be­
coming too busy to give company, the
Ganga beckons. Tirths or pilgrimages by
the waters which touch every aspect of
the average Hindu’s life (from birth cer­
emonies to obsequies) become an invit- |
ing prospect. But of late, the pilgrim has j
metamorphosed into the settler.
Unlike Varanasi, the spiritual envi­
rons of Hardwar have not been overrun ous players bu t the trend ca ught on soon
by humanity. So an increasing number after. In 1998 when vast numbers of peo­
of elderly people is investing in property ple attended the Kumbh Mela, many el­
in the Hardwar-Rishikesh stretch. Till a | ders decided to spend the rest of their lives
merefive years ago itwis as difficult spot- there.
there. According
According to
tn him.
him ““Many
Miinv older
nlder
ting apartment blocks here as spotting people have long nursed a dream of own­
tigers in the nearby Rajaji National Park. ing a house on the
... Ganga: it’s three
Temples, ashramsand hotels dominated | things they want: the river, closeness to
the skyline. But all that began changing I

1NTERLU
nature and satsang. This place is ideal for
them and they can find many others like
themselves to interact, with." Freehold
cottages in varying levels of utility or
luxury are also beginning to dot the land­
scape. AsShehzad Ahmed, managing di­
rector, Shivalik Ganga Estates (I lardwar)
says, “Pensioners tired of big cities like to

panirllv
Ito I RESIDENTS of Aradhana Sthal Apartments, Rishikesh, share a moment of peaceful
rapidly and
and Indav
today it
it ic
is Actimutorl
estimated ithat

there are no less than 200 apartment I reflection at the ghat before afternoon satsang. They feel that
blocks in the area with many more still
being constructed. With competition
hotting up between builders, most
apartments come fully furnished. Many
complexes offer thoughtful little touches
like a temple within the compound and
transportation to the ghats in time for
morning satsangs (prayer meetings) and
evening arti.
Ashok Agarwal, managing director
of Aradhana Builders (Rishikesh) re­
members a time not long ago when he
was considered foolish for entering the
apartments business. In 199 3-94 when
he began Aradhana Sthal. the first of his
many apartments, there were few seri58

INDIA TODAY ♦ JULY 16. 2001

I
1

/ 01

IN THE SUPREME COUR : OFfINDIA,CIVIL EX IRA0R1DINARY
ORIGINAL JURISDICTION

WRIT PETITION (CIVIL) NO,301 OF 2000
Under Article 32 of the constitution of India

Centre; for Enquiry & Allied Themes .
(CEHAT) and 12 Others
Verses

Peti tioners

Union of India,

th rough the Secreta ry,
Ministry of Health 8( Family Welfare,

Nirman Bhawan,

New Delhi
and 27 others-

Respondents

COUNTER AFFIDAVIT FILED ON

BEHALF OF

THE GOVERNMENT OF TAMIL NADU

I,

L,Tripathy S/o T hi ru.M.N,T ripa thy,

Hindu,

aged about

52 years residing at A3/6, Games Village, Koyambedu, Chennai-104.
do hereby solemnly affirms and state as follows :

01.

Iz am

the

Secretary

to

the Covernment of

Tami 1

Nadu,

Health and Family Welfare Department and I am acquainted with the

facts of this case from the rejcords.

02.

*

I submit that this writ petition has been filed under

the Constitution

Article 32

of

Litigation

seeking

a

of

declaration

India as a

that

Public

Pre-Natal

Interest

i ncluding

i

-2pre-pregnancy

Ac t,

1994

and

purview

and

(Regulation

1994)

of

(CA 57

the

wi thin

falls

Diagnostict Techniques

Pre-Natal

Misuse)

selection

sex

the

Prevention

of

to

the

di rections

for

of

various state Governments to ensure that Appropriate Authorities
are set up at various district levels and in some states at the
state levels as required under the above Act.

Further directions

had also been sought for to the Central Supervisory Board to meet
every

mon ths

six

as

stipulated

under

the

and

Act

the

relief

prayed in the writ petition are stated to be necessary to avoid
discrimination on the ground of sex under Articles 14 and 15 of

the Constitution of India.

03.

I submit

that I.he Government of India have enacted an

Act termed as fhe Pre-Natal Diagnostic Techniques (Regulation and

Prevention of Misuse) Act,
20 th

1994

Sep tember

1994, herein after called the Act on
an

wi th

objective

to

provide

for

the

regulation of the use of pre-natal diagnostic techniques for the
purpose

detecting

of

or

genetic

metabolic

disorders

or

T

chromosomal abnormalities or certain congenital malformations or

sex linked disorders and for
misuse

of

such

de term i na t i o n

techniques

leading

to

the prevention and curbing of

the

pre-natal

sex

for

the

female

purpose

of

foeticide

and

for

ma tters

-3-

therewith

connected

or

This

thereto„

incidental

act

is

applicable to the whole of India except the state of Jammu and

This Act
Kashmir.
has come into force
/
publication in the official Gazette.

04.

on

the

date

of

its

I submit that accordingly this Act has been notified in

the Gazette of India under section 1(3) of the Act to come into
force on the 1st January 1996 vide publication in the Gazette of
India

Extraordinary part

no.57 of 1994 .

II section

1

dated 20-09”1994

as

Act

On the advice of Government of India this State

Government have published the said Act in part IV section 4 of
the Tamil Nadu Government Gazette dated the 17th May 1995. Hence
a

notification

in

was published

Tamil

Nadu

Government Gazette

Extraordinary dated 09-02-1996.

05.

I submi t

that

in exercise of

sub-section (2) of section 17 of the

the powers conferred by

Act the Governor of Tamil

Nadu appointed the Director of Medical and Rural Health Services
as Appropriate Authority for

the

purpose

of

the

Act

as

the whole state of Tami 1 Nadu for
per

G.0.Ms.No.66.Health

Welfare Department, dated 06.02.1996.

and

Family

-4-

06.

I

submit

that

f u r Hi er

the

of

Governor

Nadu

Tami 1

constituted an Advisory Committee (of nine Members) headed by the

Director

Super inter'ident, .

and

Gynaecology

and

Hospitai

Government

Obsteritries

of

Institute

Women

for

and

and

ChiIdren,

Chennai-8 as Chairman to aid and advise the Appropriate Authority
in conformity with the powers conferred by sub-sections(5)

and

order

read

(6)

of

section

17

of

the

Act

vide

the

Government

above.
07. I submit that the Director of Medical and Rural Health
Services who is the Appropriate Authority for the State of Tamil

Nadu

requested the Government

that

the Appropriate Authorities

A_

and Advisory Committees may be constituted in the districts.

08.

submit

I

nominated

Department,

as

that

the

Government

of

Tamil

Nadu

have

Family

Welfare

of

Health

per

G.O.Ms.No.

431,

Heal th

and

dated

31.07.1998

the

Joint

Director

Services in the districts as Appropriate Authority and 4 member
t

Advisory Committees in the districts to assist the Joint Director
of Health Services in the districts.

The Advisory Committees in

the districts consist of one Gynaecologist and one Paediatrician

from7 the Government Institution, one member from social Services

Organisation and an Activist f rom women’s
Set ng am)

Organisation.(Mather

-5-

submit

I

09.

that

apart

f roiri

the

Appropriate Au thori ties

and Advisory Committees appointed at the State level and district

the central Government also have a Central Supervisory

levels,

the

perf orin

to

Board

funotion

and

exercise

to

this Central Advisory

the Act and

conferred on the Board under

powers

the

Board consists of

a) The Minister incharge of Ministry of Department of Family
Welfare as Chairman..
Secretary

The

b)

Government

to

India

of

incharge

of

Department of Family.Welfare as vice-chairman.
members appointed by Central Government to represent

c) Two
Ministries

Central

of

Government

Woman

incharge

of

Healf h

Services

and

Child

Development and Law and Justice. »

d)

T he

Di rector

General of

of

Central

Government.

e)
*

f rom

Ten members appointed by central Government, two each

eminent

Medica1

Geneticists,

Gynaecologists

and

Obstetricians, Paediatricians, Social Scientists, representatives

of Women Welfare Organisation.

f) Three women Members

of Parliament of whom two

shall

be

elected by the Hou^e of Parliament and one by Council of States.

n)

to

Four rnemberr appointed by Central Government by rotation

r^present

the

States

and

Union

Territories

on

the

recommendations of State Government or the union Territory as the
case may be and

(h) An officer in the rank of a Joint Secretary or equivalent of

the Central Government i n charge of Fami1y Weifare as Member
Secretary

10. This Central Supervisory Board is empowered by the Act

(a) to advise the Government on policy matters relating to use of
Pre-natal diagnostic techniques (b) to review implementation of

the Act and the rules made thereunder and recommend changes in
the said

Act and rules to the Central Government (c) to create

/

public ciwareness against practice of pre-natal de termi nation of

sex and female foeticide (d) to lay down code of conduct to be

obsor ved

by persons

work ing at Genetic

Counsel 1 ; .ng

Centres,

Genetic Laboratories £ind Clinics and (o) any other functions as

may be specified under the Act.
11 . I submit that on and from the date of commencement

of the Act no genetic Counselling Centre, Geneti c Laboratory or
Genet1c C1inio un1 ess registered under
t

•

associate with or help in conducting

the Act shall conduct or
activities relating to

--7Pra-'natal diagnostic techniques 01 employ any person who does not
possess

the

nd conduct

the p r e s c r 1 b e’d q u a 1 i f i cation

Pre-natal

diagnostic technique's at’the place other than a place registered

Vihe re a n i nstitu te5

under this Act.

any place by whatever
Genetic

Counsel1ing

Clinics

or

any

Nursing Home or

Hcspitai,

re a me called provides services jointly of

Genetic

Centre,

curnb inati.cn

of

requiremants as specified in

these

it

shal 1

Genetic

and

Laboratories

to

conform

the

registered u nde r

the Act and get

Appropriate Authority for the regulation in future.

<

12.

I submit that in exercise of the powers conferred

under section

19(1) of the Act the Appropriate Authority grants

registration

to

the

Laborate r i es/Geneti c

Genetic

Clinics

for

the

purpose

of

diagnostic

Pre-natal

Counsel]ing,

Ce n 11e/Ge ne ti c

Counsel1ing

Genetic

carrying

OU t

namely

tests

Chromosomal studies. bio chemical studies and molecular studies

U1 trasound,

Amnio

Centesis, Chorionic Villi Biopsy, Poetoscopy, foetal Skin

Organs

Pre-Natal

and

Diagnostic

procedures

namely

biopsy and cordocentesis’ respectively.

13.

I

submit

tha I

a 11

these

counsel1ing

centres,

/

Genetic

Laboratories or

Gene tic C1inics should no t

conduct or

i

cause

to conduct in

the J r a f o r e s a i d ’ i n s t i t u t ions the Pre natal

diagnostic techniques for the pu rposa of derm? ni ng the sex of

-8-

foetus and the persons conducting Pre natal diagnostic techniques
should not communicate

to

the pregnant women concerned or

her

relatives the sex of the. foetus by words. signs or in any other
/

pursuance

manner

in

Whoever

contr avenes any

of

rules

the

under

prescribed

the

Act.

i

of

this Act

the provisions of

or any

rules maae thereunder shall be punishable with imprisonment for a
term

which may extend

to

th ree

years

or

wi th

f i ne

which

may

extend to ten thousand rupees.

14 .

I submi t

that

Chis being the case duly regulated

u nde r the Act the petitioners No.

(1) Cent re for e nqui r i ng in to

*

Health and Allied Themes (CEHAT) based in Pune and Mumbai

No.(2)

in

Pune,

Mahila

UtKarsh

Sarvangeen

Mandal

(MASUM)

based

Me^harash tra and No. ( 3) Thi ru Sabu- M.George who had his academic

in

training

'U n i ve r s i t y

public

Schoo 1

of

Heal th

and

Nutrition

Hygiene

and

Public

at

Heal th

Johns

Hopkins

Baltimore

and

Cornell University New York have jointly filed this writ petition
in

this

Honourable

Pre-imolantat i ona1

Cou rt

wherein

Genetic

Diagnosis

it

was

( PGD)

sta ted

is

a

that

the

complicated

technique which can be misused for identifying and discarding the
f e m ale e mb r y u a nd it i s v i o 1 a t. i v e o r the intention and purpose of
the Act

and requested this Honourable Court

to issue mainly a

direction/daclaration of a nature that Pre-implantstional Genetic

Diagnosis Technique cont.ra'/enes the provisions of the Act and

hence the performance of such a procedure is violative of the

Act.

The petitioners have also prayed the Honourable Court to

di rect

the

respective

State

Governments

and

the

Central

Government to implement the provisions of the Act by appointing
Appropriate Authorities (State and District Level) and Advisory

Committees and to direct the Central Government to ensure that

the Central

Supervisory Board under the

Act meet every six

/

months as stipulated under the Act and also to direct banning of
all advertisements of nrA-natal sex selection including all other

sex deterrnination techniques which can be abused to

1 actively

produce only male babies either before or during pregnancy.
15.

I

admi t

that

the

pre -imp1antati oral

genetic

Diagnosis (PGD) could be misused to identify and to discard the
female embryo before an embryo is implanted in the uterus of a
woman in view of an extensive and complicated techniques adopted

In this artificial exercise done for the sake of reproduction or
a child.
16.

I therefore submi t that it is necessary to bring

a the above said e>:crc Lse for pro--implantational Genetic Diagnosis
also within the purview and meaning of the

Act whether it is

pre-natal o r ■ p r e imp1 antationa1 genetic procedure wi th sui table
amendment tc the Act. for strict Governance and enforcement of the
Act in letter and spirits

“10~

17.

ha ve

/

I submit 11

app o i n ted

CommiLtees

bo th

t this State Government of Tamil Nadu

the

App} op r ,i a te

Author!ties

at

S ta Le

bistrict

and

and

the

Advisory

levels

as

exp 1 a i necl

al ready .

18.

I submi t.

that sufficient advertisements have been
----------

published in the widely read English Dailies like The Hindu and
the New

Indian

Thanthi

and

Express

and

D inama1 ar

Tami 1

Dai les

wi tli

due

persons/professiona1s concernod

to

like

Dinamani,

caution

Daily

to

the

ref rain from using the Pre

natal diagnostic techniques for’determination of sex of a foetus
and

that

the

act

of

misuse

of

those

techniques

for

sex

one

Law

and

/ -

determination

a

of

foetus

is

punishable

under

J us t i ce.
submi t

19. I

that

the

Central

Constituted under the Act is empowa r ed a s

Supervisory

Board

pe r section 16 of the

Act to revi ew the i mp 1 emon ta 11or) of • the Ac t and the rules made
thereunder and recommend changes in the said Act and rules to the
Cen t ra1 Gov ernmen t.

20..

I

submit

exhausted t he open

that

I Ire

petitioners

o ption ava i1ab1e to them

have

not

to represent

this

here!n

aspect to the Central Supervisory Board for immediate observation
and consideration for necessary amendment to the rules he re? in to

/

-11i

extend

the

sphere

of

the

so

as

to

include

thr

P re- imp la.n tat i ona 1 genetic diagnosis within
the scope <md frame
work of the Act, Without, taking
any effort to pu t f or th their
case to the knowledge of
Central Supervisory Board,
they have
filed writ Potition in this
Honourable
Court
for remedial
measures.
21.

I submi t

tha t the Act was published in
the Government

of Gazette on 20tli September

1994 .

The Act cams i n to

Tamil Nadu with effect from 01.01.1996 by
published

on

21.12.1995.

In

order

to

Provisions of the Act the Government of
* -s

State

Advisory

Committee

by

a

effectively

c

enforce

the

Tamil Nadu TcrrTstT-fetbted a

Government

the Government Gazette.

in

a Gazette Notification

Or der

G. .Ms.Ho.66 Heal th Department
dated 06.02.1996.
notified in

force*

issued

This was

In G. 0 „ Ms.. Ho,

431

in

also

Heal th

Depar tment da ted 31.07.1996 the
State Government also or;dered the
constitution of the District Advisory Commithne^
he Director of
Medical and Hural Heal th
Services was nominated as
Appropriate
Au t ho r i t y to i rnp1©men t the Act
at this S ta te level.
T he Joint
Di rector of Health Services
of the district
concerned was
nominated as the Appropriate Authority at the district
level.

/

i

-12-

I

3 »jbfn i I

I.! ta t

the

Hot i. f leat. ions

also pub1isbed i r i 1 e << d i r) g d a. i 1 i e s o 1
i

regarding

the

Act was

the state hoth i n Tami1 and

•

English to draw attention of

those engaged in Genetic Counselling

to corns for ward to register

111emse 1 ves u nde r the above Act, The

details of

the newspapers wliicli carri ed t h e pu b 1 i c a t i o n are as

fC11OWS-

SLNO. NAME Of

1

THE NEWSPAPER

EDI T IONS

DATE Of' PU8LTCATI0H

1.

Dinama1a r

All

24.04,1999

2.

Dina I .ar ,?n

All

25.04.1999

3.

Murosoli

Chennai

23.04 . .1999

4.

Daily Thanthi

All

23.04.1999

5.

Ind ia n E xpr e ss

Sou I:.her n

24.04.1999

6.

Dina Mani

All

25.04.1999

7.

Kathiravan

All

26.04.1999

8.

Daily Thanth1

All

27.05.1999

9.

Indian Express

Southern

27.05.1999

10.

Indian Express

Sou then s

05.06.1999

11.

Daily lhanthi

All

05.06.1999

12.

D i naM a n i M a r u t hu va ma lai'

01.09.2000

/
i

-•13 ■

23.

I

subrni I.

that

the

above

narration

of

f acts

wou .1 d

clearly and categorically shew that the state of Tarni 1 Nadu had

taken necessary and pioper steps for the effective implementation
of

the Act.

Efforts are also made

against the ills and evils o f

to create public awareness

Pro~Natai Sex Determination Test.

The/fact that there are only two reported
cases in Tamil Naud in

a span of about seven years is i’ndic^tive of the effective steps
taken by the Governrnent i n this regard.

24.

I submit that this respondent perused the SLP

t he pe t i t ione r s a nd the facts narrated therein.
the various averments contained therein

th is

Wi tli

filed by

regard to

respondentent begs

to s ubmit the fo11owing facts f or the appropriate appreciation of
t h e i. s s u e s i n v o 1 ved x n this wr i t pe t i t i on.

25.

I submit tfi a t the •3.vo,rfiie.nts containcd in para 1 of

the

facts in brief contained in SLP is not applicable to the state of
f ami 1 Nadu as i t pe r ta i ns to the correspondence which took place

between the Senior Deputy Director General of ICMR and Additional
Secretary and Advisor to the Planning Commission.

26.

I submit that the averments contained in para 2 of the

pe t i t i o n re1ates to the refusal of ,the Director General of ICMR
to fun ’ project on natural
so?<

and

it

is

no L

to

approach towards
the

knowledge

pi e-determination

of

this

of

respondent.

“14-

27. As regards para 3 of this petition. which contains the

objects and salient provisions of the Act I submit
Genetic

Pre-Implantational

The

certainly assist

in selection of

Diagnostic

an

as follows.

well

Procedure

embryo which artificially
The purpose and

fertilised on adoption of complicated technique.

object of the above Act is to prevent the misuse of diagnostic
female foeticide and

technique for

object

of

Act

the

made

be

should

it

to effectively achieve

applicable

the
to

pre-implantational genetic diagnostic by extending the scope of
the Act to all the embryo to be implanted or already implanted
and also to the foetus evolved through natural copulation.

The

necessity to strike a balance of equality between male and female
for the survival of human race cannot be disputed.
28. The averments contained in paras 4,5 and 6 do not relate
to this respondent and hence not traversed.

29.

As regards the averments contained in para 7 I submit
Act was introduced to enforce the application of

that the above
the

techniques

identifying

for

the

constructive

and

curative

purposes

of

the genetic chromosomal of metobolic disorders and

not for the destructive purposes of sex discrimination and sex
determination of

also makes

rules

foetus for collateral

it clear

that

be

punished

would

whoever

with

considerations.

contravenes

The Act

the Act and

imprisonment

and

the

fine.

-1530.

As regards para 8 of the petition I submit that the

female foetus is the mother for introduction of the Act and it

has been enacted for strict implementation on introduction of the
Act as many as 940 Genetic Laboratories/Clinics in the state of

Tamil Nadu have applied for proper registration and regulation
under the Act of which 561 Clinics/Laboratories in the state of
Tamil Nadu have been duly examined and registered under the Act.
And keen interest is shown to this field for bringing all the

Genetic Clinics/Laboratories in the state of Tamil Nadu under

proper regulation/Governance as prescribed in the Act.

On the

advice of the Government of India the State Government of Tamil
A

Nadu have published the said Act in part IV section 4 of the
Tamil Nadu Government Gazette dated 17.05.1995 and the Government

of Tamil Nadu have appointed the Director of Medical and Rural
Health Services Chennai-6 as Appropriate Authority for the whole
state of Tamil Nadu and the Joint Director of Health Services in

the districts of Tamil Nadu

as Appropriate Authority for

the

4

purpose of this Act as per G.O.MS.No.66 Health and Family Welfare
Department, dated 05.02.1996 and G.0.Ms-No.431 Health and camily
Welfare Department,dated 31.07.1998.
Nadu

have

also

constituted

the

The Government of

Advisory Committee

both

Tamil
at

the

“16-

State

level

Authority

and

for

district

effective

level

to

assist

the

Appropriate

implementation/monitoring

of

the

said

Act.

31. The averments contained in

9 to 13 of the petition

are facts which are not to the knowledge of
the respondent and

hence they are not traversed.

32.

As regards the submissions contained in the Grounds it

is stated that the purpose and object
of

dealt

within

.detail

and

the

the Act are already

interpretation

placed

by

the

petitioner in Ground No.l is a matter for consideration by
this
Honourable Court.
X A

33.

As

regards

the

averments

contained

in

Ground

No.2

regarding the selective destruction of female embryo it is
stated
that only two cases had been reported in
the State of Tamil Nadu
which

do

not

Procedures.

relate

The

above

to

Pre-implantational

two

cases

related

Genetics

to

Diagnosis

sex ^canning

of

pregnant women.

34. As regards Ground No.3 it
is stated the State of Tamil

Nadu has taken effective steps to curb the evils of Pre-Natal
sex
determination and to prevent the misuse of such
technique.

35.

The averments contained in Ground No.4 and 5 are legal

submissions
Court.

placed

for

the

determination

of

this

Honourable

-17The averments contained

36.

in Ground No.6

and 7 do

not

relate to this respondent nor does it apply to the state of Tamil
Nadu.

37.

The averments contained in Ground No.8 and 9 do

not

relate to this respondent.
38.

I submit that the averments contained in Ground No. 10

is indicative of the effective steps taken by the State of Tamil

Nadu to compel the registration of the centres established for
Medical

Scanning.

commencement

It

this

of

submitted

that

on

Act

many

as

is

application

from

forms

from

940

the

Genetic

tate ofTafnilNaduhaveobtained"The

Clinics/Laboratories in the

proper

as

and

f ice

of

the

Director

f

Medical and RuiraT Health Services, Chennai-6 for registration as
per the Act of which only 602 applications have been received in

the office of the Director of Medical and Rural Health Services
for

issue

of

Certificates.

registration

registration

certificates

applications

received

have

been

As
issued

many

as

561

against

602

4

received

in

the

office

as
of

on
the

date

and

only

Director of

Health Services are under process.

41

applications

Medical

and

Rural

It is further submitted that

keen efforts are being taken to get the Genetic Clinics/Genetic

Laboratories functioning without authorisation duly examined and

registered

for

further

regulation

as

per

the

Act.

-18-

As

39.

regards

Ground

it

No.11

is

stated

that

the

allegation regarding the failure to prosecute the erring clinics
Appropriate action had been

do not apply to state of Tamil Nadu.

taken against those violating this Act. It is submitted that when

it was brought to

the

notice of

Appropriate Authority

’Centre for infertility

that a Genetic Clinic named as

level)

(state

functioning at

tests and Assisted Reproductive Technologies

53-B, west perumal street, Madurai was doing sex selection before

the Joint Director of Health Services , Madurai at

conception.

Usilampatti who was appointed as Appropriate Authority at the

level

district

has been directed

to

file a case

against

the

erring Dr.P.A. Chandrasekaran for criminal offence deliberately
committed by him in contravention to the provisions of the Act.
Further it is submitted that another case of similar nature was

reported in Dharmapuri District of Tamil Nadu and it is submitted

that

the Superintendent of

Police,

Bargur has registered a criminal

All

Police Station,

Women

case No.16/98 and filed

the

charge sheet in this regard.

40. I submit that the Central Supervisory Board constituted
under

review

the

Act

the

is empowered under section

implementation

of

the

Act

16

and

of
the

the Act to
rules

made

thereunder and recommend changes in the said Act and rules to the
Central Government.

-1941. I submit that the petitioners therein have not exhausted

the open option available to them to represent this aspect to the
Central

Supervisory

Board

for

i mmed i ate

observation

and

consideration for necessary amendment to the rules therein and to
extend sphere of the Act so as to include the Pre-imp!antational

the Act

Genetic Diagnosis within the scope and frame work of

effort to put forth

any

without taking

knowledge of Central

to the

Supervisory Board they have filed writ

petition in the Honourable Court

42.

thei r case

for remedial measures.

1
.'1

In view of the above submissions I submit that the

state of Tamil Nadu has taken pioneering efforts in preventing

the misuse and abuse of the Pre-Natal Diagnostic Techniques and
continues to monitor and implement the provisions of the above

Act by setting up
Committees

and

by

State

Level

associating

and

District Level

Advisory

social

welfare

voluntary

the

organisations

for

effectively

The high Male/Female? ratio in the state of Tamil

implementing

provisions

of

the

Nadu compared to the National Average testifies to the steps

Act

I

-9 '

-20/

taken by the State Government ip this regard.

Hence it is prayed

that this Honourable Court may be pleased to pass appropriate

orders deemed fit and proper in the circumstances of the case and
thus render justice.
/

Solemnly affirmed
at Chennai this the

2nd day of

Before me
Secretary to Government of
Health and Family Welfare Depa. unent
.. Chennai-600 QQ9

April 2001 and signed

his name in my presence.

Attested
Deputy Secretary to
i Government
Health and Familyy Welfare Dept.
Secreuriat, Chennai-*#® OW

f
V\3 YA

"S •

GOVERNMENT OF KARNATAKA

No.CSSM. 53/94-95.

State Family Welfare Bureau,
Directorate of Health & F.W.Services,

Bangalore. 9, Dt 3rd July 2000

CIRCULAR
You may be well aware that the prenatal diagnostic technique ( Prevention & Misuse)
Act 1994, has come into force from 1st January 1996. The Appropriate Authority and the
Advisory Committee constituted under this Act are functioning at the state level.

The District Health & F.W. Officer has been appointed as the Appropriate Authority for
each of the District. The Advisory Committee at the district level is yet to be constituted.
So far, 11 centres have been registered in the State and certificate of registration has
been issued under the said Act. It has not become possible to show good performance
in implementation of this Act ( atleast registration of the Clinics) due to lack of interest
from your end. By this time, you should have brought under this Act all the Institutions
both Government and private institutions where there is Genetic counsilling Centre/
Genetic Lab/ Genetic Clinic/ Ultra Sound Machine Centres through registration of these
centres.
During the workshop jointly sponsored by IMA & UNICEF , the poor performance in the
implementation of this Act received serious attention which should be noted.
Therefore, it is decided to take up the registration of the Centres on a serious note and
show better performance in the coming days.

As per the Act, item No.5, each centre should furnish the details in the application along
with a fee of Rs.4000/- in the form of demand draft payable in the name of Director of
Health & F W Services,Bangalore for taking further action. Five sets of Form A is
herewith enclosed for necessary action.
It is requested to give wide publicity through IEC activities and Taluk Health Officers so
that large number of institutions will get registered under this act in a couple of months.
Atleast 10 centres per district shall be targeted for getting registered in the coming 3
months*; .«<.

Communication material regarding this subject over leaf may be used.

Director
Health & F W Services,Bangalore
copy / ■'

1. All Dist.Health & FW Officers,
2. All Divisional Joint Directors
Copy submitted :
1. Principal Secretary to Govt., HFW, M.S.Buildings, Bangalore
2. Commissioner, HFW, Ananda Rao Circle, Bangalore.

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A

FORM A
(See rules 4(1) and 8(1)
(TO BE SUBMITTED IN DUPLICATE)
WITH SUPPORTING DOCUMENTS AS ENCLOSURES,
ALSO IN DUPLICATEFORM OF APPLICATION FOR
REGISTRATION OR RENEWAL OF REGISTRATION OF
A GENETIC COUNSELLING CENTRE/ GENETIC LABORATORY
/ GENETIC CLINIC*
1. Name of the Applicant
(Specify Sri/Smt/ Kum/Dr.)

2. Address of the applicant

3. Capacity in which applying
(Specify owner/partner/ managing
director/other-to be stated)
4. Type of facility to be registered
( Specify Genetic Counselling
Centre/ Genetic Laboratory /
Genetic clinic/ any combination
of these.
________________
5. Full name and address/ addresses
of Genetic counselling Centre/
Genetic Laboratory / Genetic
clinic with Telephone/Telegraphic
Telex Fax E.Mail numbers.
6. Type
of
ownership
and
organisation
(specify individual
ownership / partnership/ company
/ co-operative /any other). In case i
of type of organisation other than j
individual
ownership, furnish i
copy of articles of association and ;
names and addresses of other I
persons
responsible
for!
management as enclosure.______
7. Type of Institution (Govt., Hospital
/ Municipal Hospital /
Public
Hospital / Private
Hospital / j
Private clinic/ Private Nursing
home / Private Laboratory/ any
other to be stated.
diagnostic '
8. Specific
prenatal
procedure/ tests for
which i
approval is sought (for example j
amniocentesis,
chorionic
villi ’
aspiration/
chromosomal
/
biochemical / molecular studies
etc.,)
Leave blank if registration sought i
for Genetic Counselling centre j
only.
i

•9. Space
available
for
the
Counselling Centre. 7 Clinic/
Laboratory give totaf work area
excluding lobbies, waiting rooms,
stairs etc and enclose plan.)___
10. Equipment available with the
make
and
model
of each
equipment, list to-be attached on a j
.
separate sheet)
11. (a) Facilities available in the
counselling centre.
(b) whether facilities are available !
in the
laboratory/clinic for the following
tests:
(I) Ultrasound
(ii) Amniocentesis
(iii) Chorionic villi aspiration
j
(iv) Foetoscopy
i
v) Foetal biopsy
I
vi) Cordocentesis
(c) whether facilities are available
in the
laboratory/clinic
(I) Chromosomal studies
(ii) Biochemical studies
(iii) Molecular studies
12. Names, qualifications, experience
and
registration number of
employees, may be furnished as I
an enclosure (Refer schedules (
l.llor III)
________________i
13. State
whether
the
Genetic
Counselling
Centre/
genetic
Laboratory/Genetic clinic *
*
qualified for registration in terms of
minimum requirements laid down
in schedule I, II and III and if not,
reasons therefor. _______________
14. For renewal applications only:a) Registration No.
b) Date of issue and date of expiry of
existing certificate of registration.
15. List of Enclosures:Please attach a list of enclosures I
giving the supporting documents |
enclosed to this application.[

Date:
Place:-

Name and Sign^.ure of the applicant

; i
/

/

DECLARATION
l,Sri/Smt/Kum/Dr
wife
of

aged...

years resident of.

hereby declare that I have read and understood the Pre-natal
Diagnostic Techniques (Regulation and Prevention of misuse) Act, 1994 (57 of
1994) and the Pre-natal Diagnostic Techniques (Regulation and Prevention of
Misuse), Rules,1995.
(ii) I also undertake to explain the said Act and Rules to all employees of the
Genetic Counselling Centre/Genetic Laboratory/Genetic Clinic in respect of which
registration is sought and to ensure that Act and rules are fully compiled with.

Date:Place:-

Name and signature of applicant

^Strike out whichever is not applicable or not necessary. All enclosures are to be
authenticated by signature of the applicant.

ACKNOWLEDGMENT

The application in Form A in duplicate for grant'/renewal* of registration of genetic
counselling centre*/Genetic laboratory/Genetic clinic

(date).
* The list of enclosures attached to the application in Form A has been verified with
the enclosures submitted and found to be correct.
’On verification it is found that following documents mentioned in the list of
enclosures are not actually enclosed.

This acknowledgment does not confer any rights on the applicant for grant or
renewal of registration.

Signature and Designation
of
Appropriate Authority, or authorized
person in the Office of the
Appropriate Authority.

Date

SEAL

uj H •

g

One-Bay Seminar on the ‘Pre Natal Diagnostic Techniques
(Regulation and Prevention of Misuse Act)
Wednesday, 5lh March 2003

Venue:- Institution of Engineers, Ambedkar Veedhi, Bangalore

Organized by
The Directorate of Health & Family Welfare Services, Govt, of Karnataka
Voluntary Health Association of Karnataka
Family Planning Association of India, Bangalore
Background:- hi India, the female child population in the age group of 0-6 years has
fallen from 945 per thousand males in the 1991 census to 927 in the 2001 census. In
certain cases the tall is alarming with Punjab, which had a 0-6 vis. female population of
875 pci thousand males in the 1991 census having presently 791 pci thousand nmir
children. In the present scenario, female foeticide has become common while it was
female infanticide earlier. The misuse of technological innovations like the ultrasound
machine. Amniocentesis and Chorionic Villus Sampling (CVS) for the Sex
Determination fests has been a crucial factor in the rising number of abortions of female
fetuses.

The PNDT Act was enacted in 1994 after a prolonged struggle by concerned members of
society and various women’s organizations. Despite this act having been in force for 9
years now, there has been not even a single conviction for female foeticide countrywide.
With these facts in mind, this seminar was organized to raise awareness about the act not
just among the doctors but also the members of the public especially the women.
I’loceedings ol the Seminar:

The seminar began w ith a Sharing of Experience by Dr. B.S. Ramamamurthy, renowned
sonologist form Bangalore. Dr. Ramamurthy spoke about the pressures through which
doctors are put through by the parents and the family to reveal the sex of the child. But
the doctor has to be steadfast in refusing to divulge any such information especially now
with the strict provisions of the Act. He revealed that many doctors while doing a
chromosomal analysis also do not report on the types of sex chromosome but only
whether they arc normal or not.
I he formal inauguration of the program followed this frank talk by the doctor. The key
note address was delivered by Dr. Manorama Thomas, Emeritus Professor, St. John’s
Medical College. She said that the aim of the seminar was to raise awareness about the
declining sex ratio and about the act. The purpose of the act was to prevent misuse of
genetic techniques for the identification of the sex of a child for foeticide.

The problem was very acute in the states of Punjab, Haryana and Punjab and also in some
parts of southern India like Salem district in Tamil Nadu. There had been some cases in

families wherein ’diaupadi’ system was being followed with one bride lor 2 3 brothers
because of the lack of women in the community. Interestingly, the ‘Charakha Samhita’,
the ancient Indian treatise on medicine also mentions technique for sex determination
using the pregnant women’s urine. The PNDT act was passed in 1994 and published m
the Karnataka gazette in January 1996; the advisory committee was established in
February 1996. The committee started registration of the ‘antenatal genetic counseling &
techniques’ clinics. However it was soon realized that the advances in ultrasound made it
possible for the sonologist to be able to predict the sex of the baby by scan after the 12"
week of gestation and hence an amendment was brought in the Act to bring in ultrasound
scan centers under the ambit of the Act- this move had met a lol ol piotesl and in
Karnataka, the professionals in Bangalore and Mangalore were very vociferous in their
opposition to this amendment.
This was important as the sex ratio had fallen in the various districts in Karnataka except
Hassan , Udupi and DK districts. Some of the doctors were not directly mentioning the
sex of the baby but rather using terms like ‘jalcbi’ for the female foetus and ‘laddu’ for
the male foetus. As this was not a part of the records maintained at the centre, the
committee could not do anything about it.
The need of the hour was to change the mentality of preference for males, but it had to be
accepted that this was rather difficult.

Dr. Thimmaiah, Project Director, RCH, Karnataka then mentioned the responbilities of
the state appropriate authority ( Project Director, RCH). He said that each of the 27
districts of the state had a district appropriate authority. More than 1300 organizations
had been registered, but only 31 implicated for practices against the provisions of the law.

Mr. Kogadu Thimappa, the Hon'ble Minister for H &FW and information then formally
inaugurated the seminar. He spoke about the dual personality that was persisting in the
Indian psyche wherein we try to be scientific in our outlook but at the same time we are
bound by our social beliefs. We cannot claim to have social and gender equality until we
look upon n lady and a genl coming out of a room together in the same light as two men
coming out together I here is a need for a consistent movement, campaign and debate.
I he practice of sex determination is more among the educated class who arc aware about
the relevant technology and in many cases also know the doctors who will oblige them
unfortunately, this seems to be catching up even among the rural iolk with the
mushrooming of mobile clinics. He said that the information dept, of the state govt, was
very good at making posters and other educational material but a token 5000 posters
would not change the mindset of a population in the state running into several lakhs. I le
expressed happiness that there were several young college girls in the audience w ho were
the future mothers and would benefit the most from the seminar.

Mrs. Subhadra Venkatappa from the Family Planning Association of India (Bangalore
branch) delivered the presidential address in which she highlighted the fact that as a
society, we need to be able to say an emphatic no to these abominable practices. She
reiterated the fact that the misuse of the available technology was most by the educated

7

I
t

■* c

class. Both women and men need to work together to address this social problem. Female
or male, the child still belonged to the parents. Perhaps, a partnership between the civic

society and the government would help.
Dr. S.V. .loga Rao, a famous health law consultant gave a detailed explanation of the Act.
ile began by saying that we were in the midst of pervasive technology, be it IT or BT.
Any technology has a positive side and a negative side and this holds true for the medical
technology also. At this point of time, the actual birth of the baby is not required to be
able to know the sex of the baby but technology can do the same during the period of
gestation only. The main aim of the technology was to diagnose and treat but the
incidental finding was the sex of the fetus, a fact that could be misused. There was an
ardent need for regulation of the technology. In India, the medical termination of
pregnancy had been allowed in special conditions under law by the MTP act of 1972 and
these provisions had been misused rampantly for female foeticide. All of society and not
just the population in the reproductive age group is instrumental in the problem. By law,
the Sex Determination Tests (SDTs) like amniocentesis can be used for the diagnosis in
certain conditions like the woman’s age being above 35 years, history ol previous
abortions, and family history of chromosomal disorders but adequate records mentioning
the reasons need to be maintained. At present, the law is there, the structures are there,
but the practices continue unabated. When the Supreme Court enquired about the fact that
how many clinics had been registered across the country, 15 states feigned ignorance
about the existence of the Act! SDTs were the cause of the victimization of the voiceless
by a network, which could include the mother, father, in laws, the doctor and the
brokers/touts. Already there were ads which proclaimed 1 If you want a boy, contact Dr. X
between 10 & 11’ maybe the day was not far when we would get promos saying :If you
want your child to be the next Sachin Tendulkar, contact at this time’. The need for
regulation of the centers and proper documentation was needed but it' was to be
remembered that it was still possible to communicate the sex of the foetus in indirect
ways. In India, we were experts in passing the buck. A few cardiologists, nephrologists
using ultrasound machines had questioned their inclusion in the act but the court had
clarified that any machine that is capable of picking up the sex of the foetus has to be
registered. Three rcgistcrations have to be done- that of the place, the machine and the
centre; this was to make sure that the relevant authorities knew who was doing the tests
and where to address the issue of mobile clinics. At the end of the day, the PNDT Act
was a simple Act but it had a lot of social ramifications. Records in all registered centers
had to be kept for a period of two years unless a criminal ease was ongoing wherein they
had to be maintained beyond two years. Sometimes it was not the doctor conducting the
test who was disclosing the sex of the foetus but some other accomplice and the new
amendment in the Act had made this also illegal. The new amendments made it also
illegal Io indulge in techniques of pre conccptional sex determination (the infamous ad
controversy regarding the ad of GenSclect in leading daily in Bangalore was mentioned)
and the new title of the act was now the Pre natal/Prc conception Sex Determination
Regulation and Prevention of Misuse Act.
Dr. Kamini Rao from the Bangalore Assisted Conception Centre spoke about the medical
professionals and highlighted that it was for the health professionals and the activists to

3

not be on opposite sides but to join hands to address the menace. I he blacklisting ol the
medical profession due to the practices of a few was unjustified and unwarranted ‘doctor
bashing1 needed to be stopped. The doctors could not go to the streets and do dharnas and
morchas to present their case. The Dept, of Health & Family Welfare, which Dr. Kamini
Rao had voluntarily approached for registration of her centre did not have any idea about
the procedure involved for six years. Unfortunately, there was a lol ol mistrust about
doctors developing in the masses. FOGSI, which was the national body for Obstetricians
and Gynecologists and consisted of 18000 professional members and more than 150
branches across the country had opposed the female foeticide and supported the
empowerment ol w omen. Education was not just teaching of the alphabet but the change
needed to be in the heart of the person which would stop mothers Irom allow ing their
own daughters to be killed. Unless a multi pronged strategy was adopted to target the
women who asked for the test, the family who was pressurizing her to do that and the
doctor who agrees to do the test, it was difficult to make much progress. She stresses that
doctors were ready to pledge at any forum their support for this campaign as they stood
for the health of humanity - it was unfair to look upon them with jaundiced eyes.

Ms. Shantala, a senior correspondent with a local daily presented her thoughts about the
role of the media, which comprised the fields of advertising, films, radio, television and
newspapers. She reminded the audience about the controversy that had erupted when the
soap ‘Kyunki Saas Bhi Kabhi Bahu Thi’ had shown pre natal sex determination in one of
the episodes. While Article 19( 1 )a of the Constitution gave the freedom of speech. Art
19(2) also imposed reasonable restrictions and this was a clear violation of those. She had
been offered a fellowship to study the PNDT act implementation in one district of
Karnataka. Ms. Shantala had chosen Mandya as it happened to be the constituency of the
Chief Minister. Mandya was a predominantly agricultural area and the feudal system still
persisted. The first child in a family was expected to be a boy and there were cases
whcicin women who had Iwo daughters had .subsequently undci pone live conseculix c
abortions (after SD I s) in the ‘quest* of a son. I he sex ratio in these areas was among the
low est in the stale with Maddur registering 910 and Srirangapatna 890 in the age group 0() years. In a small locality called Ashoknagar in Mandya, there were around 15 nursing
homes; most with scan centers attached, which wuie involved in the practice. Theses
places preferred the uneducated who would haw no knowledge of the law . The bail was
the slogan ‘5000 spent now will save you 5 lacs later1. It was package deal wherein a
middleman/ANM would help the patient get through the entire process of a SDT and an
abortion, if needed for Rs. 5000 in a couple of days; the doctor would send the patient to
a scan centre w hich would not give any report but only a chit of paper w ilh I or w ritten
on it which the referring doctor would interpret and act accordingly. I he process was
supposed to save the patient and her family the sum of Rs 5 lacs that they would have to
spend on their daughter’s marriage in the future should she be allowed to be born and
raised up.
Dr. H. V. Ramprakash, a radiologist elaborated on the role of the voluntary organizations.
He explained that a major reason for the increasing scan centers were because of
increased role of ultrasound in the fields of medicine- only 10/100 patients approaching
sonologists were pregnant antenatal women. He hastened to add that however there were

4

I

122 female children dying for every 100 male children dying in the 0 4 yeais age group.
The number ofdowry deaths had also been showing an upward trend. The NGOs had an
important role to play. Female literacy and health awareness was a major component and
the high literacy levels in Kerala and the healthy sex ratio there was an indicator of the
importance of this step. Some TBAs had a belief that they needed to kill the 3“ born girl
child as it was supposed to bring harm to the attendant. There was also lhe problem ol
neglect of lhe girl child and the battered baby syndrome- in these cases the mid day meal
schemes like the Akshayapatra service of ISKCON could help. We as a nation had quite a
high MMR ( 490 per 1 lakh live births which was the highest in the world ); only 30% ol
lhe deliveries taking place were being handled by the trained stall. In lhe productive age
group of 15-48 years, there were only 906 women per thousand males. I here were more
than 7 lakh abortions a year in the country while the govt, claimed that it was only around
60,000(bccause only these many got registered). Identification ol mobile clinics that
conducted SDTs and closing them was also something the NGOs needed to lake up with

lhe govt.
The discussion was then thrown open to the audience. Dr. Manorama opined that il the
falling sex ratio continued, then the practice of dowry would stop and that ol bride money
would start. Another lady said that it was important to treat every child as a human being
not as a male or a female; society needed to accord respect to a woman, whether she
decided to get married or remain unmarried, whether she was having a child or was
childless. A doctor in the audience said that the dowry deaths were being encouraged by
women themselves- including mothers-in -law or sisters-in-law. A young college girl
responded to this very frankly and asked that this might be true, but what was the
husband doing at that time? If the husband was supportive, then no other relative could
cause harm to the woman. Another doctor ventured to say that there were a lot ol
educated young people who were coming forward to undergo permanent sterilization
even if they had a single child. We needed to respect ourselves and other human beings
irrespective of sex. The purpose of the seminar was not to encourage the hatred of men
but to develop a feeling of mutual regard. A case wherein a junior engineer had asked the
doctor to kill his 3ld girl child was narrated
the doctor asked the person to donate the
child bill lhe person refused saying that lie did nol wanl his wile to know that the child
had suiu\cd so that she could gel pregnant a fourih lime. Interestingly, this couple had
not gone in for a SDT because some local deity they had prayed to had purportedly told
them that they would get a.son this time. The condition was so abysmal in some places
like the Erode Hospital that ayahs had to be posted to wards having recently born female
babies to prevent any killing. Dr. Manorama mentioned that some of the ultrasound scan
centers were telling the patient about the sex of the foetus as early as the 10/1 l" week of
gestation when the test could only predict with some degree of accuracy only after lhe
12lh week of gestation- this accuracy was limited to 85% in the case of scans and 90% in
the case of Chorionic Villus Sampling. This was clearly just a ploy to cash in unethically
on the craze of Sex Determination.
Ms. S. Venkatappa spoke about the conceited efforts to implement the act. She said that
the purpose of such seminar was to sensitize people about the PNDT act. All the speakers
had expressed their commitment to the cause. And even the participants had been

5

I

oiii\inccd aboul the need to sensitize others; the need of the hour was the right
environment to empower people especially the women.
H.li. the Governor of Karnataka, Sri. T.N. Chaturvedi in his valedictory address
highlighted the need of establishing partnerships for removing social ills. He narrated
personal experiences ol getting to know about cases of infanticide when he was sei v mg
in Rajasthan. While the govt, was making efforts, support towards awareness and
consciousness was need. I he problem was widespread and deep looted and hence, the
society needed to be vigilant about the problem and continuously work towards helping
the message percolate to every part of the state - perhaps such seminars/workshops could
be organized in other pats of the state and the country. The declining sex ratio in Punjab
due to foeticide was surprising because one of the Sikh Gurus was emphatic in his
teachings about the women’s empowerment. It was not just the quacks and hall-baked
physicians but also respected professionals with loads of degrees who were making the
Hippocratic oath hypocritical, it was unfortunate that the legislature had not enacted the
law but it was on the direction of the Supreme Court on the basis of a PH. bled by an
individual. The practice of SDT was an affront to the constitutional rights of the ‘would
be’ citizens of the country and violation of the dignity of the individual (the importance
of dignity has been enshrined in the Preamble to the constitution). Karnataka could
perhaps take the lead in encouraging a govt.- public interface for the purpose. The
seminar was a summing up and a call for concerted action in the future.

Sex Ratio( in the age group of 0-6 years; girls per thousand boys
♦
♦

National (1991): 945
National (2001): 927

♦
♦

Karnataka (1991): 960
Karnataka (2001): 949

I )i Annul Bhan
Community Health Cell,
// 367, Srinivasa Nilaya,
Jakkasandra 1st Main, Koramangala 1st Block,

Bangalore-560 034
Tel:- 5531518
Telefax:- 5525372
E m ail:

d rbhantos i fy .com

()

I

VOH- "S

One-Bay Seminar on the ‘Pre Natal Diagnostie Techniques
(Regulation and Prevention of Misuse Act)
Wednesday. 5111 March 2003

Venue:- Institution of Engineers, Ambedkar Veedhi, Bangalore
Organized by

The Directorate of Health & Family Welfare Services, Govt, of Karnataka
Voluntary Health Association of Karnataka
Family Planning Association of India, Bangalore
Background:- In India, the female child population in the age group of (1-6 vears has
fallen from 945 per thousand males in the 1991 census to 9?7 in the 2001 census. In
certain cases the fall is alarming w ilh Punjab, which had n 0-6 vis, female population of
875 per thousand males in the 1991 census having presently 791 pri Ihoiisiiiid mule
children. In the present scenario, female foeticide has become common while it was
female infanticide earlier. The misuse of technological innovations like the ultrasound
machine. Amniocentesis and Chorionic Villus Sampling (CVS) for the Sex
Determination I csts has been a crucial factor in the rising number of abortions of female
fetuses.

The PNDT Act was enacted in 1994 after a prolonged struggle by concerned members of
society and various women's organizations. Despite this act haxing been in force for 9
years now, there has been not even a single conviction for female foeticide country^ ide.
With these facts in mind, this seminar was organized to raise awareness about the act not
just among the doctors but also the members of the public especially (he women.
Proceedings ol the Seminar:

The seminar began w ith a Sharing of Experience by Dr. B.S. Ramamamurthy. renow ned
sonologist form Bangalore. Dr. Ramamurthy spoke about the pressures through which
doctors arc put through by the parents and the family to reveal the sex of the child. But
the doctor has to be steadfast in refusing to divulge any such information cspcciallv now
with the strict provisions of the Act. He revealed that many doctors while doing a
chromosomal analysis also do not report on the types of sex chromosome but only
whether they arc normal or not.
The formal inauguration of the program followed this frank talk by the doctor. I he key
note address was delivered by Dr. Manorama Thomas, Emeritus Professor, St. John’s
Medical College. She said that the aim of the seminar was to raise awareness about the
declining sex ratio and about (he act. 1 he purpose of the act w as to prevent misuse of
genetic techniques for the identification of the sex of a child for foeticide.
I he problem was \ cry acute in the slates of Punjab, Haryana and Punjab and also in some
parts of southern India like Salem district in Tamil Nadu. There had been some cases in

families wherein ‘diaupadi’ system was being followed with one bride lor 2 ^brothers
because of the lack of women in the community. Interestingly, the '( harakha Samhila ,
the ancient Indian treatise on medicine also mentions technique lor sex delcimination
using the pregnant women’s urine. The PNDT act was passed in 1994 and published in
the Karnataka gazette in January 1996; the advisory committee was established in
February 1996. The committee started registration of the ‘antenatal genetic counseling &
techniques’ clinics. However it was soon realized that the advances in ultrasound made it
possible for the sonologist to be able to predict the sex of the baby by scan after the 12 1

week of gestation and hence an amendment was brought in the Act to bring in ultrasound
scan centers under the ambit of the Act- this move had met a lol of protest and in
Karnataka, the professionals in Bangalore and Mangalore were very vociferous in their
opposition to this amendment.
This was important as the sex ratio had fallen in the various districts in Karnataka except
Hassan , Udupi and DK districts. Some of the doctors were not directly mentioning the
sex of the baby but rather using terms like ‘jalebi’ for the female foetus and daddu’ for
the male foetus. As this was not a part of the records maintained al the centre, the

committee could not do anything about it.
The need of the liom was to change the mentality of preference for males, hut it had to be

accepted that this was rather difficult.
Dr. Thimmaiah, Project Director, RCH, Karnataka then mentioned the responbililies of
the state appropriate authority ( Project Director, RCH). He said that each ol the 27
districts of the stale had a district appropriate authority. More than 1300 organizations
had been registered, but only 31 implicated for practices against the provisions of the law.

Mr. Kogadu Thimappa, the Hon’ble Minister for H &FW and Information then formally
inaugurated the seminar. He spoke about the dual personality that was persisting in the
Indian psyche wherein we try to be scientific in our outlook but at the same time we are
bound by our social beliefs. We cannot claim to have social and gender equality until we
look upon a lady and a genl coming out of a room together in the same light as two men
coming out together. There is a need for a consistent movement, campaign and debate.
The practice of sex determination is more among the educated class who are aware about
the relevant technology and in many cases also know the doctors who will oblige them
unfortunately, this seems to be catching up even among the rural folk with the
mushrooming of mobile clinics. He said that the information dept, of the state govt, was
very good at making posters and other educational material but a token 5000 posters
would not change the mindset of a population in the stale running into several lakhs. He
expressed happiness that there were several young college girls in the audience who were
the future mothers and would benefit the most from the seminar.
Mrs. Subhadra Venkatappa from the Family Planning Association of India (Bangalore
branch) delivered the presidential address in which she highlighted the fact that as a
society, we need to be able to say an emphatic no to these abominable practices. She
reiterated the fact that the misuse of the available technology was most by the educated

•»

2

class. Both women and men ineed to work together to address this social problem. Female
or male, the child still belonged to the parents. Perhaps,, a partnership between (he civic
society and the government would help.

Or. S.V. .loga Kao, a famous health law consultant gave a detailed explanation of the Act.
He began by saying (hat we were in the midst of pervasive technology, be it IT or BT
Any technology has a positive side and a negative side and this holds true for the medical
technology also. At this point of time, the actual birth of the baby is not required to be
able to know the sex of the baby but technology can do the same during the period of
gestation only, fhc mam aim of the technology was to diagnose and treat but the
incidental finding was the sex of the fetus, a fact that could be misused There was -in
ardent need for regulation of the technology. In India, the medical termination of
picgnancy had been allowed in special conditions under law by the MTP act of 1972 ami
these provisions had been misused rampantly for female foeticide. All of society and not
just the population in the reproductive age group is instrumental in the problem. Bv law.
the Sex Dctcrminalion lests (SI) Is) like amniocentesis can be used I'oi the diagnosis in
certain conditions like the woman’s age being above 35 years, history of previous
abortions, and family history of chromosomal disorders but adequate records mentioning
the reasons need to lie maintained. At present, (he law is there, the structures are there
bul the practices continue unabated. When the Supreme Court enquired about the fact that
how many clinics had been registered across the country, 15 states feigned ignorance
about the existence ofthc Act! SDTs were the cause of the victimization of the voiceless
by a network, which could include the mother, father, in laws, the doctor and the
brokers/touts. Already there were ads which proclaimed ‘If you want a boy, contact Dr. X
between 10 & 1 1 ’ maybe the day was not far when we would get promos saying ‘If you
want your child to be the next Sachin Tendulkar, contact at this time’. The need for
icgulation of the centers and proper documentation was needed but it was to be
remembered that it was still possible to communicate the sex ofthc foetus in indirect
ways. In India, we were experts in passing the buck. A few cardiologists, nephrologists
using ultrasound machines had questioned their inclusion in the act but the court had
clarified that any machine that is capable of picking up the sex ofthc foetus has to be
registered. Three rcgistcrations have to be done- that ofthc place, the machine and the
ccntie this was to make sure that the relevant authorities knew who was doing the tests
and where to address the issue of mobile clinics. At the end of the day, the PNDT Act
was a simple Act but it had a lot of social ramifications. Records i
---------- in all registered centers
had to be kept for a period of two years unless a criminal
case was ongoing wherein they
had to be maintained beyond two years. Sometimes it
was not the doctor conducting the
test who was disclosing the sex ofthc foetus but some
• other accomplice and the new
amendment in the Act had made this also illegal, 'fhc
new amendments made it also
illegal to indulge in techniques of pre conccptional sex i
dctci mination (the in famous ad
controversy regarding the ad of GenSelect in leading daily in Bangalore
' was mentioned)
and the new title of the act was now the Pre natal/Pre
conception Sex Determination
Regulation and Prevention of Misuse Act.
Or. Kamim Ra° from the Bangalore Assisted Conception Centre spoke about the medical
professionals and h.ghhghted that it was for the health prolessionals and the actS io

3

not be on opposite sides but to join hands to address the tnenaee. the blacklisting ol the
medical profession due to the practices of a few was unjustified and unwarranted ‘doctor
bashing’ needed to be stopped. The doctors could not go to the streets and do dharnas and
morchas to present their case. The Dept, of Health & Family Welfare, which Dr. Kamini
Rao had voluntarily approached for registration of her centre did not have any idea about
the procedure involved for six years. Unfortunately, there was a lol ol mistrust about
doctors developing in the masses. FOGSI, which was the national body foi Obstetiicians
and Gynecologists and consisted of 18000 professional members and more than 150
branches across the country had opposed the female foeticide and supported the
empowerment of women. Education was not just teaching ol the alphabet but the change
needed to be in the heart of the person which would slop mothers Irom allow ini', their
own daughters to be killed. Unless a multi pronged strategy was adopted to target the
women who asked for the test, the family who was pressurizing her to do that and the
doctor who agrees to do the test, it was difficult to make much progress. She stresses that
doctors were ready to pledge at any forum their support for this campaign as they stood

for the health of humanity -it was unfair to look upon them with jaundiced eyes.
Ms. Shantala, a senior correspondent with a local daily presented her thoughts about the
role of the media, which comprised the fields of advertising, films, radio, television and
new spapers. She reminded the audience about the controversy that had erupted when the
soap ‘Kyunki Saas Bhi Kabhi Bahu Thi’ had shown pre natal sex determination in one of
the episodes. While Article 19(l)a of the Constitution gave the freedom of speech. Art
19(2) also imposed reasonable restrictions and this w as a clear violation ol those. She had
been offered a fellowship to study the PNDT act implementation in one district of
Karnataka. Ms. Shantala had chosen Mandya as it happened to be the constituency of the
Chief Minister. Mandya was a predominantly agricultural area and the feudal system still
persisted. The first child in a family was expected to be a boy and there were cases
wherein women who had two daughters had subsequently undergone five consecutive
abortions (after SI) I s) in the ‘quest’ of a son. The sex ratio in these areas was among the
low est in the stale w ilh Maddur registering 910 and Srirangapatna 890 in the age group 0() vc.us In a small locality called Ashoknagar in Mandya, there were around 15 nursing
ImiiH

ino.-.l with ;a.in cunlciH attached, which wciu involved in lliu piaclicc.

Illeses

places preferred the uneducated who would have no knowledge ol the law . I he bail was
the slogan ‘5000 spent now will save you 5 lacs later’. It was package deal wherein a
middleman/ANM would help the patient get through the entire process of a SDT and an
abortion, if needed for Rs. 5000 in a couple of days; the doctor would send the patient to
a scan centre which would not give any report but only a chit of paper with t or written
on it which the referring doctor would interpret and act accordingly. The process was
supposed to save the patient and her family the sum of Rs 5 lacs that they would ha\ e to
spend on their daughter’s marriage in the future should she be allowed to be born and
raised up.
Dr. H. V. Ramprakash, a radiologist elaborated on the role of the voluntary organizations,
lie explained that a major reason for the increasing scan centers were because of
increased role of ultrasound in the fields of medicine- only 10/100 patients approaching
sonologists were pregnant antenatal women. He hastened to add that however there were

4

122 female children dying for every 100 male children dying in the 0-4 years age group.
The number of dowry deaths had also been showing an upward trend. The NGOs had an
important role to play. Female literacy and health awareness was a major component and
the high literacy levels in Kerala and the healthy sex ratio there was an indicator of the
importance of this step. Some TBAs had a belief that they needed to kill the 3ld born girl

child as it was supposed to bring harm to the attendant. I here was also the problem of
neglect of the girl child and the battered baby syndrome- in these cases the mid day meal
schemes like the Akshayapatra service of ISKCON could help. We as a nation had quite a
high MMR ( 490 per 1 lakh live births which was the highest in the world ); only 30% of
the deliveries taking place were being handled by the trained staff. In the productive age
group of 15-48 years, there were only 906 women per thousand males. I here were more
than 7 lakh abortions a year in the country while the govt, claimed that it was only around
60,000(because only these many got registered). Identification of mobile clinics that
conducted SDTs and closing them was also something the NGOs needed to take up with
the go\ l.

I he discussion was then thrown open to the audience. Dr. Manorama opined that if the
falling sex ratio continued, then the practice of dowry would stop and that of bride money
would start. Another lady said that it was important to treat every child as a human being
not as a male or a female; society needed to accord respect to a woman, whether she
decided to get married or remain unmarried, whether she was having a child or was
childless. A doctor in the audience said that the dowry deaths were being encouraged by
women themselves- including mothers-in law or sisters-in-law. A young college girl
responded to this very frankly and asked that this might be true, but what was the
husband doing at that time? If the husband was supportive, then no other relative could
cause harm to the woman. Another doctor ventured to say that there were a lol of
educated young people who were coming forward to undergo permanent sterilization
even if they had a single child. We needed to respect ourselves and other human beings
irrespective of sex. 1 he purpose of the seminar w as not to encourage the hatred of men
but to develop a feeling of mutual regard. A case w herein a junior engineer had asked the
doctor to kill his 3“l girl child was narrated
the doctor asked the person to donate the
child hut the prison refused saying that he did not want his wife Io know that the child
had survi\ed so that she could get pregnant a fourth lime. Interestingly, this couple had
not gone in for a SDT because some local deity they had prayed to had purportedly told
them that they would gel a son this time. The condition was so abysmal in some places
like the Erode Hospital that ayahs had to be posted to wards having recently born female
babies to prevent any killing. Dr. Manorama mentioned that some of the ultrasound scan
centers were telling the patient about the sex of the foetus as early as the 10/1 I11, week of

gestation w hen the test could only predict with some degree of accuracy only after the
12lh week of gestation- this accuracy was limited to 85% in the case of scans and 90% in

the case of Chorionic Villus Sampling. This was clearly just a ploy to cash in unethically
on the craze of Sex Determination.
Ms. S. Venkatappa spoke about the concerted efforts to implement the act. She said that
the purpose of such seminar was to sensitize people about the PNDT act. All the speakers
had expressed their commitment to the cause. And even the participants had been

5

r

convinced about the need to sensitize others; the need of the hour was the right
environment to empower people especially the women.

H.E. the Governor of Karnataka, Sri. T.N. Chaturvedi in his valedictory address
highlighted the need of establishing partnerships for removing social ills. He narrated
personal experiences of getting to know about cases of infanticide when he was serving
in Rajasthan. While the govt, was making efforts, support towards awareness and
consciousness was need. The problem was widespread and deep looted and hence, the
society needed to be vigilant about the problem and continuously work towards helping
the message percolate to every part of the state perhaps such seminars/workshops could
be organized in other pats of the state and the country. The declining sex ratio in Punjab
due to foeticide was surprising because one of the Sikh Gurus was emphatic in his
teachings about the women’s empowerment, it was not just the quacks and hall-baked
physicians but also respected professionals with loads of degrees who w ere making the
Hippocratic oath hypocritical. It was unfortunate that the legislature had not enacted the
law but it was on the direction of the Supreme Court on the basis of a Pll. filed by an
individual. The practice of SDT was an affront to the constitutional rights of the 'would
be’ citizens of the country and violation of the dignity of the individual (the importance
of dignity has been enshrined in the Preamble to the constitution). Karnataka could
perhaps take the lead in encouraging a govt.- public interface for the purpose. 1 he
seminar was a summing up and a call for concerted action in the future.

Sex Ralio( in the age group of 0-6 years; girls per thousand boys
♦
♦

National (1991): 945
National (2001): 927

♦
♦

Karnataka (1991): 960
Karnataka (2001): 949

I )i Aiianl lihan
Community Health Cell,
# 367, Srinivasa Nilaya,
Jakkasandra 1st Main, Koramangala 1st Block,
Bangalore-560 034
Tel:- 5531518
Telefax:- 5525372

Email:

drbhan(«>si fy.com

6

(/xJ VA' 3

Oiic-I);k Seminar on the "Pre Natal Diagnostic l ecliniqnes
(Regulation and Prevention of Misuse Act)
Wednesday, 5lh March 2003

Venue:- Institution of Engineers, Ambedkar Veedhi, Bangalore
Organized by
The Directorate of Health & Family Welfare Services, Govt, of Karnataka
\ oluntary Health Association of Karnataka
Family Planning Association of India, Bangalore
Background:- In India, the female child population in the age group of 0-6 years has
fallen from 945 per thousand males in (he 1991 census to 927 in the 2001 census. In
certain cases the fall is alarming with Punjab, which had a 0-6 yrs. female population of
875 pci thousand males in the I99I census having presently 7<)3 pci thousand male
children. In the present scenario, female foeticide has become common while il was
female infanticide earlier. The misuse of technological innovations like the ultrasound
machine. Amniocentesis and Chorionic Villus Sampling (CVS) for (he Sex
Determination Tests has been a crucial factor in the rising number of abortions of female
fetuses.
I he PNI) I Act w as enacted in 1994 after a prolonged struggle by concerned members of
society and various women’s organizations. Despite this act having been in force for 9
years now, there has been not even a single conviction for female foeticide countrywide.
With these facts in mind, this seminar was organized to raise awareness about the act not
just among (he doctors but also the members of the public especially the w o’men.

I’roceedings of the Seminar:

'flic seminar began w ith a Sharing of Experience by Dr. B.S. Ramamamurthy. renow ned
sonologist form Bangalore. Dr. Ramamurthy spoke about the pressures through which
doctors arc put through by the parents and the family to reveal the sex of the child. But
the doctor has to be steadfast in refusing to divulge any such information cspeciallv now
with (he strict provisions of the Act. He revealed that many doctors while doing a
chromosomal analysis also do not report on the types of sex chromosome but only
vv hether they arc normal or not.
I he formal inauguration of the program followed this frank talk by the doctor. The key
note address was delivered by Dr. Manorama Thomas, Emeritus Professor, St. John’s
Medical College. She said that the aim of the seminar was to raise awareness about the
declining sex ratio and about the act. The purpose of the act w as to prevent misuse of
genetic techniques for the identification of the sex of a child for foeticide.
I he problem was \ cry acute in the states ol Punjab, Haryana and Punjab and also in some
pai ls of southern India like Salem district in Tamil Nadu. There had been some cases in

families wherein ‘draupadi’ system was being followed with one bride lor 2-3 brothers
because of the lack of women in the community. Interestingly, the T'harakha Samhila’,
the ancient Indian treatise on medicine also mentions technique lor sex determination
using the pregnant women’s urine. The PND1 act was passed in 1994 and published in
the Karnataka gazette in January 1996; the advisory committee was established in
February 1996. The committee started registration of the ‘antenatal genetic counseling &
techniques’ clinics. However it was soon realized that the advances in ultrasound made it
possible for the sonologist to be able to predict the sex of the baby by scan after the 12lh
week of gestation and hence an amendment was brought in the Act to bring in ultrasound
scan centers under the ambit of the Act- this move had met a lol ol piotest and in
Karnataka, the professionals in Bangalore and Mangalore were very vociferous in their

opposition to this amendment.
This was important as the sex ratio had fallen in the various districts in Karnataka except
Hassan , Udupi and DK districts. Some of the doctors were not directly mentioning the
sex of the baby but rather using terms like ‘jalebi’ for the female foetus and laddif for
the male foetus. As this was not a part of the records maintained al the centre, the

committee could not do anything about it.

The need of the hour was to change the mentality of preference for males, but it had to be
accepted that this was rather difficult.

Dr. Thimmaiah, Project Director, RCH, Karnataka then mentioned the lesponbilities of
the stale appropriate authority ( Project Director, RCH). He said that each ol the 27
districts of the slate had a district appropriate authority. More than 1300 organizations
had been registered, but only 31 implicated for practices against the provisions ol the law.

Mr. Kogadu Thimappa, the Hon’ble Minister for H &FW and Information then formally
inaugurated the seminar. He spoke about the dual personality that was persisting in the
Indian psyche wherein we try to be scientific in our outlook but al the same lime we are
bound by our social beliefs. We cannot claim to have social and gender equality until we
look upon a lady and a gent coming out of a room together in the same light as two men
coming oul logclhci I here is a need for a consislenl movement, campaign and debate.
The pi adieu of sex dctui ininalion is more among the educated class who arc aware about
the relevant technology and in many cases also know the doctors who will oblige them
unfortunately, this seems to be catching up even among the rural folk with the
mushrooming of mobile clinics. He said that the information dept, of the stale govt, was
very good at making posters and other educational material but a token 5000 posters
would not change the mindset of a population in the state running into se\ cral lakhs. He
expressed happiness that there were several young college girls in the. audience who were
the future mothers and would benefit the most from the seminar.
Mrs. Subhadra Venkatappa from the Family Planning Association of India (Bangalore
branch) delivered the presidential address in which she highlighted the fact that as a
society, we need to be able to say an emphatic no to these abominable practices. She
reiterated the fad that the misuse of the available technology was most by the educated

2

class. Both women and men need to work together to address this social problem Female
or male, the child still belonged to the parents. Perhaps, a partnership between the civic
society and the government would help.

Dr. S.V. Joga Rao, a famous health law consultant gave a detailed explanation of the Act.
He began by saying that we were in the midst of pervasive technology, be it IT or BT.
Any technology has a positive side and a negative side and this holds true for the medical
technology also. At this point of time, the actual birth of the baby is not required to be
able to know the sex of the baby but technology can do the same during the period of
gestation only. The mam aim of the technology was to diagnose and treat but the
mc.dental finding was the sex of the fetus, a fact that could be misused. There was an
ardent need or regulation of the technology. In India, the medical termination of
picgnancy had been allowed in special conditions under law by the MTP act of 1972 and
these provisions had been misused rampantly for female foeticide. All ofsocicty and not
just the population in the reproductive age group is instrumental in the problem' By law
the Sex Determination Tests (SDTs) like amnioe-niesis can be used foi the diammis in
ccitam conditions like the woman’s age being above 35 years, history of previous
abortions, and family history of chromosomal disorders but adequate records mentioning
the reasons need to be maintained. At present, the law is there, the structures are there,
but the practices continue unabated. When the Supreme Court enquired about the fact that
how many climes had been registered across the country, 15 states feigned ignorance
about the existence of the Act! SDTs were the cause of the victimization of the voiceless
by a network, which could include the mother, father, in laws, the doctor and the
brokers/touts. Already there were ads which proclaimed ‘If you want a boy, contact Dr. X
between 10 & II
maybe the day was not far when we would get promos saying ‘If you
want your child to be the next Sachin Tendulkar, contact at this time’. The need for
regulation of the centers and proper documentation was needed but it was to be
remembered that it was still possible to communicate the sex of the foetus in indirect
ways. In India, we were experts in passing the buck. A few cardiologists, nephrolomsts
using u Unsound machines had questioned their inclusion in the act but the court "’had
clarified that any machine that is capable of picking up the sex of the foetus has to be
legisteied. fbice icgistcrations have to be done- that of the place, the machine and the
centic this was to make sure that the relevant authorities knew who was doing the tests
and whcic to address the issue of mobile clinics. At the end of the day, the PNDT Act
was a simple Act but it had a lot of social ramifications. Records in all registered centers
had o be kept for a period of two years unless a criminal case was ongoing wherein they
had to be maintained beyond two years. Sometimes it was not the doctor conducting the
test who was disclosing the sex of the foetus but some other accomplice and the^new
amendment m the Act had made this also illegal. The new amendments made it also
illegal to mdulge in techniques of pre conccptional sex determination (the infamous ad
conlioveisy icgardmg the ad of GcnSclcct in leading daily in Bangalore was mentioned)
and the new til e of the act was now the Pre natal/Prc conception Sex Determination
Regulation and {’rcvention of Misuse Act.

Dr. Kamini Rao from the Bangalore Assisted Conception Centre spoke about (he medical
professionals and highlighted that it was for the health professionals and the activists to

3

not be on opposite sides but to join hands Io address the menace. I he blacklisting ol the

medical profession due Io the practices of a few w as unjustified and unw arranted ‘doctor
bashing’ needed to be stopped. The doctors could not go to the streets and do dharnas and
morchas to present their case. The Dept, of Health & Family Welfare, w hich Dr. Kamini
Rao had voluntarily approached for registration of her centre did not have any idea about

the procedure involved for six years. Unfortunately, there was a lol ol misirusl about
doctors developing in the masses. FOGSI, which was the national body for ()bsleli icians
and Gynecologists and consisted of 18000 professional members and more than 150

branches across the country had opposed the

female foeticide and supported the

empowerment of women. Education was not jusl leaching of the alphabet bul the change
needed to be in the heart of the person which would slop mothers from allow ing their
own daughters to be killed. Unless a multi pronged strategy was adopted to target the
women who asked for the test, the family who was pressurizing her to do that and the

doctor who agrees to do the test, it was difficult to make much progress. She stresses that
doctors were ready to pledge at any forum their support for this campaign as they stood
lot the heallh ol humanity

it was unfair to look upon them with jaundiced eyes.

Ms. Shantala, a senior correspondent with a local daily presented her thoughts about the
role of the media, which comprised the fields of advertising, films, radio, television and

newspapers. She reminded the audience about the controversy that had erupted when the

soap ‘Kyunki Saas Bhi Kabhi Bahu Thi’ had shown pre natal sex determination in one of

the episodes. While Article 19( 1 )a of the Constitution gave the freedom of speech, Art
19(2) also imposed reasonable restrictions and this was a clear violation ol those. She had

been offered a fellowship to study the PNDT act implementation in one district of
Karnataka. Ms. Shantala had chosen Mandya as it happened Io be the constituency of the

Chief Minister. Mandya was a predominantly agricultural area and the feudal system still
persisted. The first child in a family was expected to be a boy and there were cases
wdiercin w'omen who had two daughters had subsequently undergone five consecutive
abortions (after SD I s) in the ‘quest’ of a son. The sex ratio in these areas was among the

lowest in the stale with Maddur registering 910 and Srirangapalna 890 in the age group 00 years. In a small locality called Ashoknagar in Mandya, there were around 15 nursing
Ihiinc.1., mo.1.1 w ith scan centers attached, which were involved in the practice'. I heses
places preferred the uneducated who would have no knowledge of the law. I he bait was
the slogan ‘5000 spent now will save you 5 lacs later’. It was package deal wherein a
middleman/ANM would help the patient get through the entire process of a SDT and an

abortion, if needed for Rs. 5000 in a couple of days; the doctor would send the patient to
a scan centre which would not give any report but only a chit of paper with + or

written

on it which the referring doctor would interpret and act accordingly. The process was
supposed to save the patient and her family the sum of Rs 5 lacs that they would have to
spend on their daughter’s marriage in the future should she be allowed to be born and
raised up.

Dr. H. V. Ramprakash, a radiologist elaborated on the role of the voluntary organizations.
He explained that a major reason for the increasing scan centers were because of
increased role of ultrasound in the fields of medicine- oni) Io I 00 patients approaching
I I dial however there were
sonologists were pregnant antenatal women lie hastened

4

/

122 female children dying for every 100 male children dying m the 0 4 years age group.
The number oITIovm) Jcaths had also been showing an upward trend. The NGOs had an
important role to play. Female literacy and health awareness was a major component and
the high literacy levels in Kerala and the healthy sex ratio there was an indicator of the
importance of this step. Some TBAs had a belief that they needed to kill the 3“ born girl
child as it was supposed to bring harm to the attendant. There was also the problem ol
neglect of the girl child and the battered baby syndrome- in these cases the mid day meal
schemes like the Akshayapatra service of 1SKCON could help. We as a nation had quite a
high MMR ( 490 per 1 lakh live births which was the highest in the world ); only .30% of
the deliveries taking place were being handled by the trained stall. In the productive age
group of 15-48 years, (here were only 900 women per thousand males. I here were more
than 7 lakh abortions a year in the country while the govt, claimed that it was only around
60,000(because only these many got registered). Identification of mobile clinics that
conducted SDTs and closing them was also something the NGOs needed to take up with
the govt.
The discussion was then thrown open to the audience. Dr. Manorama opined that il the
falling sex ratio continued, then the practice of dowry would stop and that ol bride money
would start. Another lady said that it was important to treat every child as a human being
not as a male or a female; society needed to accord respect to a woman, whether she
decided to get married or remain unmarried, whether she was having a child or was
childless. A doctor in the audience said that the dow ry deaths were being encouraged by
women themselves- including mothers-in -law or sisters-in-law. A young college girl
responded to this very frankly and asked that this might be true, but what was the
husband doing at that time? If the husband was supportive, then no other relative could
cause harm to the woman. Another doctor ventured to say that there were a lol ol
educated young people who were coming forward to undergo permanent sterilization
even if they had a single child. We needed to respect ourselves and other human beings
irrespective of sex. The purpose of the seminar was not to encourage the hatred of men
but to develop a feeling of mutual regard. A case wherein a junior engineer had asked the
doctor to kill his 3“' girl child was narrated - the doctor asked the person to donate the
i liild bul the pel son refused saying that he did not want his wife to know that the child
had survived so that she could get pregnant a fourth time, interestingly, this couple had
not gone in for a SDT because some local deity they had prayed to had purportedly told
them that they would get a son this time. The condition was so abysmal in some places
like the Erode Hospital that ayahs had to be posted to wards having recently born female
babies to prevent any killing. Dr. Manorama mentioned that some ol the ultrasound scan
centers were telling the patient about the sex of the foetus as early as the 10/11"1 week of
gestation when the test could only predict with some degree of accuiacy only aftei the
1211’ week of gestation- this accuracy was limited to 85% in the case of scans and 90% in
the case of Chorionic Villus Sampling. This was clearly just a ploy to cash in unethically
on the craze of Sex Determination.

Ms. S. Venkatappa spoke about the concerted efforts to implement the act. She said that
the purpose of such seminar was to sensitize people about the PNDT act. All the speakers
had expressed their commitment to the cause. And even the participants had been

5

f

I

coin incud aboul Ihu need to sensitize others; the need ol the hour was the right

en\ ironmenl to empower people especially the women.

H.E. the Governor of Karnataka, Sri. T.N. Chaturvedi in his valedictory address
highlighted the need of establishing partnerships for removing social ills. He narrated
personal experiences of getting to know about cases of infanticide when he was serving
in Rajasthan. While the govt, was making efforts, support towards awareness and
consciousness was need. I he problem was widespread and deep looted and hence, the
society needed to be vigilant about the problem and continuously work towards helping
the message percolate to every part of the state - perhaps such seminars/workshops could
be organized in other pats of the state and the country. The declining sex ratio in Punjab
due to foeticide was surprising because one of the Sikh Gurus was emphatic in his
teachings about the women’s empowerment. It was not just the quacks and hall-baked
physicians but also respected professionals with loads of degrees who were making the
Hippocratic oath hypocritical. It was unfortunate that the legislature had not enacted the
law but it was on the direction of the Supreme Court on the basis of a PIL filed by an
individual. The practice of SDT was an affront to the constitutional rights of the ‘would
be’ citizens of the country and violation of the dignity of the individual (the importance
of dignity has been enshrined in the Preamble to the constitution). Karnataka could
perhaps take the lead in encouraging a govt.- public interface for the purpose. The

I

seminar was a summing up and a call for concerted action in the future.
Sex Ratio( in the age group of 0-6 years; girls per thousand boys
♦
♦

National (1991): 945
National (2001): 927

♦
♦

Karnataka (1991): 960
Karnataka (2001): 949

I )i. An.ml Bhan
Community Health Cell,
# 367, Srini\ asa Nilaya,
Jakkasandra 1st Main, Koramangala 1st Block,

Bangalore-560 034
Tel:- 5531518
Telefax:- 5525372
Email:

drbhanfqisi fy.com

1

6

v\' H— 'S

()ne-l)ay Seminar on the ‘Pre Natal Diagnostic I echniques
(Regulation and Prevention of Misuse Act)
Wednesday, 5,h March 2003
Venue:- Institution of Engineers, Ambedkar Veedhi, Bangalore
Organized by
The Directorate of Health & Family VS clfare Services, Govt, of Karnataka
Voluntary Health Association of Karnataka
Family Planning Association of India, Bangalore
Background:- In India, the female child population in the age group of 0-6 years has
fallen from 945 per thousand males in the 1991 census to 927 in the 2001 census. In
certain cases the fall is alarming w ith Punjab, which had a 0-6 yrs. female population of
875 per thousand males in the 1991 census having presently 793 per thousand nude
children. In the present scenario, female foeticide has become common while it was
female infanticide earlier. The misuse of technological innovations like the ultrasound
machine. Amniocentesis and Chorionic Villus Sampling (CVS) for the Sex
Determination Tests has been a crucial factor in the rising number of abortions of female
fetuses.

I hc PNDT Act was enacted in 1994 after a prolonged struggle by concerned members of
society and various women's organizations. Despite this act having been in force for 9
years now. there has been not even a single conviction for female foeticide countrywide.
With these facts in mind, this seminar was organized to raise awareness about the act not
just among the doctors but also the members of the public especially the w omen.
Proceedings of the Seminar:

J he seminar began w ith a Sharing of Experience by Dr. B.S. Ramamamurthy, renow ned
sonologist form Bangalore. Dr. Ramamurthy spoke about the pressures through which
doctors arc put through by the parents and the family to reveal the sex of the child. But
the doctor has to be steadfast in refusing to divulge any such information especially now
with (he strict provisions of the Act. He revealed that many doctors while doing a
chromosomal analysis also do not report on the types of sex chromosome but only
whether they arc normal or not.

I hc formal inauguration of the program followed this frank talk by Ihc doctor. 1 he key
note address was delivered by Dr. Manorama Thomas, Emeritus Professor, St. John's
Medical College. She said that the aim of the seminar was to raise aw areness about the
declining sex ratio and about (he act. I hc purpose of the act was to prewent misuse of
genetic techniques for the identification of the sex of a child for foeticide.
I he problem w as \ ei y acute in the slates of Punjab, Haryana and Punjab and also in some
parts ol southern India like Salem district in Tamil Nadu. There had been some cases in

/

families wherein ‘draupadi’ system was being followed with one bride for 2-3 brothers
because of the lack of women in the community, interestingly, the ‘Charakha Samhita’,
the ancient Indian treatise on medicine also mentions technique for sex determination
using the pregnant women’s urine. The PND1 act was passed in 1994 and published in
the Karnataka gazelle in January 1996; the advisory committee was established in
February 1996. The committee started registration of the ‘antenatal genetic counseling &
techniques’ clinics. However it was soon realized that the advances in ultrasound made it
possible for the sonologist to be able to predict the sex of the baby by scan after the 12,h
week of gestation and hence an amendment was brought in the Act to bring in ultrasound
scan centers under the ambit of the Act- this move had met a lol of protest and in
Karnataka, the professionals in Bangalore and Mangalore were very vociferous in their
opposition to this amendment.
This was important as the sex ratio had fallen in the various districts in Karnataka except
Hassan , Udupi and DK districts. Some of the doctors were not directly mentioning the
sex of the baby but rather using terms like ‘jalebi’ for the female foetus and ‘laddu’ for
the male foetus. As this was not a part of the records maintained al the centre, the
committee could not do anything about it.

I he need of the hour was to change the mentality of preference for males, but it had to be
accepted that this was rather difficult.
Dr. Thimmaiah, Project Director, RCH, Karnataka then mentioned the responbilities of
the state appropriate authority ( Project Director, RCH). He said that each ol the 27
districts of the stale had a district appropriate authority. More than 1300 organizations
had been registered, but only 31 implicated for practices against the provisions ol the law.

Mr. Kogadu Thimappa, the Hon'ble Minister for 11 &FW and Information then formally
inaugurated the seminar. He spoke about the dual personality that was persisting in the
Indian psyche w herein we try to be scientific in our outlook but at the same time we are
bound by our social beliefs. We cannot claim to have social and gender equality until we
look upon a hid\ and a genl coming out of a room together in the same light as two men
coming out together I here is a need for a consistent movement, campaign and debate.
Ihe practice of sex determination is more among the educated class who arc aware about
the relevant technology and in many cases also know the doctors who will oblige them
unfortunately, this seems to be catching up even among the rural folk with the
mushrooming of mobile clinics. He said that the information dept, of the slate govt, was
very good al making posters and other educational material but a token 5000 posters
would not change the mindset of a population in the slate running into several lakhs. He
expressed happiness that there were several young college girls in the audience who were
the future mothers and would benefit the most horn the seminar.

Mrs. Subhadra Vcnkatappa from the Family Planning Association of India (Bangalore
branch) delivered the presidential address in which she highlighted the fact that as a
society, we need to be able to say an emphatic no to these abominable piactices. She
reiterated the fact that the misuse of the available technology was most by the educated

2

class. Both women and men need to work together to address this social problem. Female
or male, the child still belonged to the parents. Perhaps, a partnership between the civic
society and the government would help.
Dr. S.V. Joga Rao, a famous health law consultant gave a detailed explanation of the Act.
He began by saying that we were in the midst of pervasive technology, be it IT or BL
Any technology has a positive side and a negative side and this holds true for the medical
technology also. At this point of time, the actual birth of the baby is not required to be
able to know the sex of the baby but technology can do the same during the period of
gestation only. The main aim of the technology was to diagnose and treat but the
incidental finding was the sex of the fetus, a fact that could be misused. There was an
ardent need for regulation of the technology. In India, the medical termination of
pregnancy had been allowed in special conditions under law by the MTP act of 1972 and
these provisions had been misused rampantly for female foeticide. All of society and not
just the population in the reproductive age group is instrumental in the problem. By law,
the Sex Determination Tests (SDTs) like amniocentesis can be used for the diagnosis in
certain conditions like the woman’s age being above 35 years, history of previous
abortions, and family history of chromosomal disorders but adequate records mentioning
the reasons need to be maintained. At present, the law is there, the structures aie there,
but the practices continue unabated. When the Supreme Court enquired about the fact that
how many clinics had been registered across the country, 15 states feigned ignorance
about the existence of the Act! SDTs were the cause of the victimization of the voiceless
by a network, which could include the mother, father, in laws, the doctor and the
brokers/touts. Already there were ads which proclaimed ‘If you want a boy, contact Dr. X
between 10 & 11’- maybe the day was not far when we would get promos saying ‘If you
want your child to be the next Sachin Tendulkar, contact at this time . 1 he need foi
regulation of the centers and proper documentation was needed but it was to be
remembered that it was still possible to communicate the sex of the foetus in indirect
ways. In India, we were experts in passing the buck. A few cardiologists, nephrologists
using ultrasound machines had questioned their inclusion in the act but the court had
clarified that any machine that is capable of picking up the sex of the foetus has to be
registered. Three rcgistcrations have to be done- that of the place, the machine and the
centre; this was to make sure that the relevant authorities knew who was doing the tests
and where to address the issue of mobile clinics. At the end of the day, the PNDI Act
was a simple Act but it had a lot of social ramifications. Records in all registered centers
had to be kept for a period ol'two years unless a criminal case was ongoing wherein they
had to be maintained beyond two years. Sometimes it was not the doctor conducting the
lest who was disclosing the sex of the foetus but some other accomplice and the new
amendment in the Act had made this also illegal. The new amendments made it also
illegal to indulge in techniques of pre conccptional sex determination (the infamous ad
controversy regarding the ad of GcnSclcct in leading daily in Bangalore was mentioned)
and the new title of the act was now the Pre natal/Prc conception Sex Determination
Regulation and Prevention of Misuse Act.

Dr. Kamini Rao from the Bangalore Assisted Conception Centre spoke about the medical
professionals and highlighted that it was for the health professionals and the activists to

3

nol be on opposite sides but to join hands to address the menace. I he blacklisting ol the
medical profession due to the practices of a few was unjustified and unw arranted ‘doctor
bashing’ needed to be stopped. The doctors could nol go to the streets and do dharnas and
morchas to present their case. The Dept, of Health
Family Welfare, which Dr. Kamini
Rao had voluntarily approached for registration of her centre did not have any idea about
the procedure invoked for six years. Unfortunately, there was a lol ol mistrust about
doctors developing in the masses. FOGSI, which was the national body loi Obstcti icians
and Gynecologists and consisted of 18000 professional members and more than 150
branches across the country had opposed the female foeticide and supported the
empowerment ol women. Education was not just teaching of the alphabet but the change
needed to be in the heart of the person which would stop mothers Irom allowing their
own daughters to be killed. Unless a multi pronged strategy was adopted to target the
women who asked for the test, the family who was pressurizing her to do that and the
doctor who agrees to do the test, it was difficult to make much progress. She stresses that
doctors were ready to pledge at any forum their support for this campaign as they stood
for the health of humanity -it was unfair to look upon them with jaundiced eyes.
Ms. Shantala, a senior correspondent with a local daily presented her thoughts about the
role of the media, which comprised the fields of advertising, films, radio, television and
newspapers. She reminded the audience about the controversy that had erupted when the
soap ‘Kyunki Saas Bhi Kabhi Bahu Thi’ had shown pre natal sex determination in one of
the episodes. While Article 19( 1 )a of the Constitution gave the freedom of speech. Art
19(2) also imposed reasonable restrictions and this was a clear violation of those. She had
been offered a fellowship to study the PNDT act implementation in one district of
Karnataka. Ms. Shantala had chosen Mandya as it happened to be the constituency ol the
Chief Minister. Mandya was a predominantly agricultural area and the feudal system still
persisted. I he first ehild in a family was expected to be a boy and there were cases
wherein women who had two daughters had subhcqucntly undergone five consecutive
abortions (after SD I s) in the ‘quest’ of a son. I he sex ratio in these areas was among the
lowest in the slate with Maddur registering 910 and Srirangapatna 890 in the age group 06 years In a small locality called Ashoknagar in Mandya, there were around 15 nursing
Ihhiic'., mo'.l with .'.can centers attached, which wcic invoked in the piatlue Ihcscs
places preferred the uneducated who would have no knowledge of the law. I he bait was
the slogan ‘5000 spent now will save you 5 lacs later’. It was package deal wherein a
middleman/ANM would help the patient gel through the entire process of a SDT’aiiid an
abortion, if needed for Rs. 5000 in a couple of days; the doctor would send the patichl to
a scan centre w hich w ould not give any report but only a chit of paper with i or. written
on it which the referring doctor would interpret and act accordingly. The process was
supposed io save the patient and her family the sum of Rs 5 lacs that they would have to
spend on their .daughter’s marriage in the future should she be allow ed to be born and
raised up.
Dr. 11. V. Ramprakash, a radiologist elaborated on the role of the voluntary organizations.
He explained that a major reason for the increasing scan centers were because of
increased role of ultrasound in the fields of medicine- only 10/100 patients approaching
sonologists were pregnant antenatal women. He hastened to add that however there were

4

I

122 female children dying for every 100 male children dying in the 0-4 years age group.
The number of dowry deaths had also been showing an upward trend. The N(i()s had an
important role to play, female literacy and health awareness was a major component and
the high literacy levels in Kerala and the healthy sex ratio there was an indicator ol the
importance of this step. Some TBAs had a belief that they needed to kill the 311 born girl
child as it was supposed to bring harm to the attendant. I here w as also the problem ol
neglect of the girl child and the battered baby syndrome- in these cases the mid day meal
schemes like the Akshayapatra service of ISK(4 )N could help. We as a nation had ipiite a
high MMR ( 490 per 1 lakh live births which was the highest in the world ); only xO'o ol
the deliveries taking place were being handled by the trained stall. In the productive age
group of 15-48 years, there were only 906 women per thousand males. I here weie moie
than 7 lakh abortions a year in the country while the govt, claimed that it w as only around
60,()()()(because only these many got registered). Idenliiicalion ol mobile clinics that
conducted SDTs and closing them was also something the NGOs needed to lake up with
the govt.
I he discussion was then thrown open to the audience. Dr. Manorama opined that il the
falling sex ratio continued, then the practice of dow ry would slop and that ol bride money
would start. Another lady said that it was important to treat every child as a human being
not as a male or a female; society needed to accord respect to a woman, whether she
decided to gel married or remain unmarried, whether she was having a child or was
childless. A doctor in the audience said that the dowry deaths were being encouraged by
women themselves- including mothers-in -law or sisters-in-law. A young college giil
responded to this very frankly and asked that this might be true, but what was the
husband doing at that time? If the husband was supportive, then no other relative could
cause harm to the woman. Another doctor ventured to say that there were a lol ol
educated young people who were coming forward to undergo permanent sterilization
even if they had a single child. We needed to respect ourselves and other human beings
irrespective of sex. The purpose of the seminar was not to encourage the haired ol men
but to develop a feeling of mutual regard. A case wherein a junior engineer had asked the
doctor to kill his 3rd girl child was narrated
the doctor asked lhe person to donate the
child but the peisoii refused saying that he did not want his wife to know that lhe child
had survived so that she could get pregnant a fourth lime. Interestingly, this couple had
not gone in for a SDT because some local deity they had prayed to had purportedly told
them that they would gel a son this time. The condition was so abysmal in some places
like the Erode Hospital that ayahs had to be posted lo wards having recently born female
babies to prevent any killing. Dr. Manorama mentioned that some of the ultrasound scan
centers were telling lhe patient about the sex of the foetus as early as the 10/1 llh week of
gestation when the test could only predict with some degree ol accuracy only after lhe
1211' week of geslalion- this accuracy was limiled lo 85% in the case ol scans and 90% in
the case of Chorionic Villus Sampling. This w as clearly just a ploy lo cash in unethically
on the craze of Sex Determination.

Ms. S. Venkatappa spoke about the concerted efforts to implement the act. She said that
the purpose of such seminar was to sensitize people about the PNDT act. All the speakers
had expressed their commitment to the cause. And even the participants had been

5

»>

Ctm\ meed about the need to sensitize others; the need of the hour was the right
environment to empower people especially the women.
H.E. the Governor of Karnataka, Sri. T.N. Chaturvedi in his valedictory address
highlighted the need of establishing partnerships for removing social ills. He narrated
personal experiences of getting to know about cases of infanticide when he was serving
in Rajasthan. While the govt, was making efforts, support towards awareness and
consciousness was need. The problem was widespread and deep rooted and hence, the
society needed to be vigilant about the problem and continuously work towards helping
the message percolate to every part of the state - perhaps such seminars/workshops could
be organized in other pats of the state and the country. The declining sex ratio in Punjab
due to foeticide was surprising because one of the Sikh Gurus was emphatic in his
teachings about the women’s empowerment. Il was not just the quacks and half-baked
physicians but also respected professionals with loads of degrees who were making the
Hippocratic oath hypocritical. It was unfortunate that the legislature had not enacted the
law but it was on the direction of the Supreme Court on the basis ol a PIL filed by an
individual. The practice of SDT was an affront to the constitutional rights of the ‘would
be’ citizens of the country and violation of the dignity of the individual (the importance
of dignity has been enshrined in the Preamble to the constitution). Karnataka could
perhaps lake the lead in encouraging a govt.- public interface for the purpose. 1 he

seminar was a summing up and a call for concerted action in the future.
Sex Ratio( in the age group of 0-6 years; girls per thousand boys
♦
♦

National (1991): 945
National (2001): 927

♦
♦

Karnataka (1991): 960
Karnataka (2001): 949

I h Ah.ml I Ohm
Community 1 leallh ('ell,
# 367, Srinivasa Nilaya,
Jakkasandra 1st Main, Koramangala 1st Block,

Bangalore-560 034
Tel:- 5531518
Telefax:- 5525372
Email:

drbhanfrz sify.com

6

I

W H ' S-

CAMPAIGN AGAINST SEX SELECTIVE ABORTION
^snhiei Mdfm: 11, DCamaliL 2njd.Sbftlf ^kbuui ^Iwkkikulum, Jflajdiujfai - 625 002.
& C^ax. : 530486& 524762
^huifiuh
lO-tfluMnaJL QLaqxir, JdUlf Jloufit, SaiiLaftfl, Qltfjuuu 600 015.
: 044 2353503 C^ax: 2355905

6th November 2002.
Dear friends
Greetings. We are enclosing the minutes of the CASSA’s regular meet held in Madurai

on 30th October. The major decisions were as follows:

1. SIRD, TNVHA, LEAD, Manitham, VRDP, SNEHA, SIGA, CEDA have agreed to
convene a token protest for the enforcement of PNDT Act in the light of the directions
given by the Supreme Court and demanding the AA to take action against the
violators. It was decided to request HRF, AREDS, WC, AIDWA to organise the
protest in their respective districts. CASSA will be sending the copy of the
handbill to the protesting organisations. Other members are requested to
extend their support and solidarity by their active participation to make this
protest, a meaningful effort.
2. SIRD, TNVHA, LEAD, Manitham, VRDP, SNEHA, SIGA, CEDA have agreed to
contribute some amount ranging from Rs. 1000 to Rs.5000 towards legal expenses to
implead in the counter petition filed against the PIL by Indian Radiological
Association of India. It was decided to request HRF, AREDS, WC, AIDWA, TNSF,
ACCESS and ICCW to support the legal expenses. Members are requested to
send their contribution by sending a DP in the name of Mr. M.Jeeva, Madurai,

3. Organisations like Manitham, LEAD, VRDP, TNVHA have consented to organise
education programmes for the various constituency with minimum technical support
from CASSA.
4. CASSA has received a grant of Rs.240,000/- from UNICEF for executing the
education programmes for teachers, VHNs and doctors. We request you to
communicate your willingness to execute this programme at the earliest.
5. It was agreed that CASSA should work with disability movement and other women
and health organisations lo broad base the campaign.

6. It was decided that CASSA would co-ordinate with HRF to organise a sensitisation
programmes for medical college students.

Warm regards
Yours sincerely
(P PHAVALAM)

Convenor

Encl: as above

Minutes of the Campaign Committee Meet

held at Hotel Aarthy, Madurai on 29th October 2002.
The following members were present:
Mr. A.Renganathan - VRDP, Mr. Thomas George - UNICEF, Mr. A.Jesuraj - CEDA
Trust, Ms M.Valli - SIGA Trust, Ms S.Priya - EKTA, Ms A.lndirani - SNEHA,

Mr. B.S.Vanarajan and Mr. 1.1.Robert Chandrakumar - Manitham, Mr. G.Dhanapaul TNVHA, Ms N.Radha - LEAD, Ms Jesurethinam - LAW Trust, Mr. M.Jeeva - SIRD,

Ms Gandimathi and Ms P.Phavalam.
Ms Girija Kumarababu - ICCW, Ms Mina Swaminathan - ACCESS and Dr Gabriele Centre for Social Analysis, Mr. S.A.Kanagasabapathy - SSD expressed their leave of

absence by their letters and Dr Vasanthi Devi - Tamil Nadu State Commission for
Women, Mr. Ossie Fernandes - HRF expressed their leave of absence over phone.

The convenor welcomed the members and presented the agenda for the meeting.

Ms Jesurethiam was requested to facilitate the meeting.
Agenda of the Meeting:

■

Review of our activities since last meeting.

■

Status of PNDT Act and CASSA’s response - Impleading of case filed by Indian
Radiological and Imaging Association in the Supreme Court of India

■

Future activities of CASSA and strategies to strengthen the campaign

■

Mobilising Funds

Minutes of the previous meeting was read. Discussion was initiated on the minutes. • It

was shared that the tasks such as bringing out three years report of CASSA, printing

Health Register and filing a case against Gen-Select were not carried out because of
lack of funds. Earlier, it was decided to file a case against Gen-Select. As the PIL filed

by CEHAT is pending before the SC, it was opined that CASSA may wait for the final
verdict as the new amendment will ban the Gen-Select. Moreover, CASSA is exerting
pressure on Appropriate Authority to take legal action against the owner for publication

of advertisement on Gen-Select.

In this regard, the convenor also shared that

Committee for Legal Aid to Poor (CLAP), a human rights organisation in Orissa is filing a
PIL against Gen-Select procedure.

She also added that Appropriate Authority is open for dialogue and extends support in

providing information but it is inactive in implementing the PNDT Act.

It was felt that

CASSA is left out with no option except to proceed legally against the Appropriate
Authority for its inaction against several complaints filed by CASSA.

The members

shared that the legal groups, human rights groups such as Lawyers’ Collective, People’s

Watch may be contacted for initiating legal action.

Members also suggested that the

present Health Secretary may be contacted to direct the Appropriate Authority to take
legal action against the violators. It was decided that CASSA will implead in the writ
petition filed by CLAP against Gen-Select.

Question was also raised, whether CASSA is networking with organisations in other
States. To this, the convenor responded that CASSA has informal linkages with similar
campaign forums in Punjab, ^amataka) and individual organisations/activists in
Maharashtra, Orissa and Andhra Pradesh.
Then, discussion was initiated based on the above agenda.

Review of our activities since last meeting.

Advocacy and Lobbying:

State-level consultation of NGOs was organised by Tamil Nadu State Commission for
Women in Chennai on 11th April 2002 and in Madurai on 21st June.

On behalf of

CASSA, a memorandum was submitted, highlighting the demands of CASSA for the
effective enforcement of PNDT Act, MTP Act and to protect the rights of girl children to

be bom and survive and the role of the Commission to address this issue and to extend
solidarity to CASSA.

A team of CASSA Members representing organisations such as TNVHA, HRF, CCRD,

AIDWA, SIGA, VELS, LEAD, AREDS, SIRD, VRDP and SNEHA lobbied with the
political parties and members of the legislative assembly on 2nd and 3rd May 2002, in

Chennai before the discussion on the demand for grant for Health and Family Welfare
focussing on:
Endorse the amendments proposed by CASSA on PNDT Act and recommend the
Central Government to table the amendments in the parliament.

Include sex ratio at birth and IMR Gender Differentials as health indicators

Action against the violators of PNDT Act and MTP Act

The team appealed to them to raise questions in the Assembly on the following:
Budget allocation to enforce PNDT Act;

Reasons for not organising sensitisation programme on PNDT Act, inspite of
Supreme Court orders;

Reasons for not taking action against violators of PNDT Act;
Reasons for non-functioning of advisory committee under PNDT Act

Status of implementation of MTP Act
Functioning of Health Committee and Welfare Committee in Panchayats.

Bharat Scans:

CASSA also sent a memorandum to the Appropriate Authority, giving 30 days notice,
demanding them to immediately suspend the use of 4D Realtime Ultrasound Scanner

and initiate legal proceedings against Bharat Scans under Sec 6(a) and 22(1) of PNDT
Act; to initiate legal proceedings against The Hindu and Business Line for violating Sec
22(2) of PNDT Act.
Signature campaign was organised through member organisations.

I

Supreme Court in its interim verdict on 7th October with regard to frequent appearance of

sex determination advertisement in the newspapers, ordered the State to take stem
action for such publication of advertisement. Quoting this verdict, CASSA again sent a

i

communication to the State AA, reminding them for the inaction on our petition and
requested them to expedite the process.

PNDT Act-Amendments:
Signature Campaign was organised through member organisations demanding * to

incorporate suggestions made by CASSA in the proposed draft of PNDT Act.

Memorandum to the same was sent to Central Ministry, State Ministry, National and
State Law Commission, Women’s Commission, Members of Central Supervisory Board

and political party leaders.
A team of CASSA met the State Minister of Health and Family Welfare in Perambalur

and submitted the above memorandum.

CASSA lobbied for the placement of the

proposed amendment in the parliament.

CASSA is also mobilising the support of

AIDWA and CPM to get the bill passed in the parliament.

5

Dharna Against Bharat Scan and Advertisements carried out in The Hindu and

Business Line:
Bharat Scans introduced a latest technology imported from Austria by name !4D
Realtime Ultrasound Scan’. Advertisement regarding this scan were published in ‘The
Hindu’ and ‘Business Line’ on 7th April. This technology advocates that it is a ‘window to
the womb’ and allowing an informed choice to the parents to decide on the gender.
Against this advertisement and anti-women technology, CASSA organised a state-level

Dhama in Chennai on 14th June.

About 600 people representing 39 NGOs, Women’s

Sangams, Child Rights Institutions, Institution for Disabled Children, Women’s
Movement, Political Parties extended their solidarity to the demands of the protest.

Vidyasagar openly expressed its political position on the usage of medical technologies

to eliminate the disabled children before they are bom.

They joined with CASSA to

make a joint appeal for a total ban on medical technologies. It was a stunning scene to

see the voluntary participation of specially abled children of Vidyasagar with a placard in
their hands, demanding their rights to live in this world with respect. Their participation

strengthened the spirit of the protest as well as the campaign.

As a follow-up, CASSA served notice to Bharat Scans, demanding them either to make
a public retraction for its act of violation of PNDT Act in any leading dailies or to hold a

public meeting of sonologists and making a public commitment not to misuse the
medical technologies. If ‘Bharat Scans’ is not for the options placed by CASSA and if
the Appropriate Authority did not file complaint against the Bharat Scans, it was decided

to file a private complaint in the Court against Bharat Scans.

Public Hearing:
Dr Vasanthi Devi, the Chairman of Tamil Nadu State Commission for Women hold a
public hearing on female infanticide and feticide. In this regard, she invited CASSA to
co-ordinate with SCW to organise this public hearing.

Through this joint endeavour, it

was aimed to evolve strategies and legal remedies to address the issue of female

infanticide and feticide. Victims of female infanticide and female feticide, mainly from
the districts of Madurai, Theni, Perambalur, Salem, Namakkal and Dharmapuri were

identified with the help of member organisations.

The public hearing took place in

Chennai on 10th July.

4

Of the identified 36 victims of female infanticide, female feticide, surrendering the female

infants in the Government Cradle Scheme 32 deposed before the jury team. 4 victims
failed to report. CASSA, VRDP, LEAD, SIRD, DEEPS presented papers on the day of
public hearing, on the following theme.

CASSA

: Memorandum to SCW to relieve the victims of female infanticide who

are accused guilty under Sec 302
- Presented by Ms Gandimathi

A Critical Analysis of Tamil Nadu Government Cradle Baby Scheme

- Presented by Ms P.Phavalam

SIRD

: A perspective paper on understanding female infanticide and feticide

- Presented by Mr. Jeeva

VRDP

: Socio, demographic profile of Salem district

- presented by Mr. Renganathan
DEEPS

: Socio, demographic profile of Dharmapuri District

- presented by Mr. Shankar
LEAD

: Non-enforcement of PNDT in Trichy, Erode and Perambalur Districts
- presented by Ms Radha

When the news hit the media on 27,h September 2002 that 11 fetuses were found in
Aundipatti drainage canal, CASSA sent a memorandum to the AA of Theni District, AA

of State, and Secretary to Government, Health and Family Welfare pointing out that the
incident is a clear indication of violation of PNDT Act and MTP Act and demanding them

to take immediate action to probe into the matter to trace the source of the institution
which indulge in notorious act and try them under law and to publish factual report.

UNICEF Programmes:

CASSA

carried out the following programmes for which UNICEF extended

assistance:
February 11, 12 - Sensitisation progrmme for Adolescent Girl Children in Madurai &
Theni Districts in co-ordination with SIRD and Tamil Nadu Science Forum

Feb 23, 24 - Sensitisation progrmme for Adolescent Girl Children in Erode District in
co-ordination with LEAD.

March 16, 2002 - Sensitisation programme for Panchayat Presidents on Girl Child

Rights and PNDT Act in Erode District, in co-ordination with LEAD.

April 13, 2002 - Panchayat Presidents in Theni Distict in co-ordination with Women
Development Resource Centre.
April 29, 2002 - Panchayat Presidents in Dharmapuri District in co-ordination with

DEEPS.
July 29, 2002 - sensitisation programme for Medical College Students of Madurai
Medical College.

Publications:
In connection with the programmes, CASSA prepared a Resource Manual on Girl Child

Rights focussing on 'Role of Panchayat Raj Institutions in addressing the issue of
declining child sex ratio and Reading Manual on 'Adolescent Girls Development Rights'.

Filing of Case against the violators of PNDT Act:

Case Against Dr Chandrasekar:
The case file was closed in November 2001. It was revoked again by the pressure given
by CASSA to the Appropriate Authority and the State Secretary of Health and Family
Welfare and they requested the Deputy Director of Prosecution and District Collector of
Madurai to take immediate steps to file a case against Dr P.Chandrasekar.

Sent petitions to Director of Prosecution, TN State Commission for Women, District
Collector and Director of Vigilance and Anti-Corruption, Chennai highlighting the
contradictory opinions given by APP II between 17.3.1999 and 15.11.2001 with her final

opinion that there was no material facts to initiate prosecution under PNDT Act though in
her previous opinions she stated that the clinic have violated the provisions of Sec 3, 18,

and 22 of PNDT Act and the undue delay in initiating prosecution. We requested for a
probe into the conduct of APP II and as there is a prima facie evidence to prove violation

of provisions of the Act. We also requested to speed up the process of filing a private
complaint against the doctor and render justice to womanhood.
In response, The Chairperson of TN State Commission for Women sent a letter to The

Director of Prosecution to do the investigation into the matter and asked for early
initiatives of prosecution.

6

Networking:
On, January 23, 2002, in coordination with its member organisation SIGA, organised
a training programme in Chennai, to the members of NGOs from Thiruvallur and

Kachipuram on the theme: Role of NGOs in Halting the Declining Child Sex Ratio
At the invitation of CCRD, the convenor of CASSA facilitated a session on the theme:

Preventing Female Feticide and Infanticide to the Rural Workers Organisation in
Tamil Nadu on 14th May 2002, in Perambalur.

At the invitation of LEAD, Phavalam and Gandimathi facilitated sessions on Role of

teachers to protect the rights of girl children in Trichy.
At the invitation of Family Planning Association of India - Madurai Branch, the

convenor of CASSA facilitated sessions on status of girl children in Tamil Nadu and
Role of NGOs in implementing PNDT Act to the NGO representatives.

The Central Ministry of Health and Family Welfare organised a technical meet in

Bangalore to sensitise the Appropriate Authorities of Southern States, for the

effective enforcement of PNDT Act and difficulties faced by them in the context of the
directions given by the Supreme Court. Invitation was extended to CASSA and on

behalf of CASSA, Ms Gandimathi participated and putforth our suggestions.

CASSA seriously worked with AIDWA to include the issue of declining child sex ratio
in their agenda.

In their national level meet, the issue of female infanticide and

feticide was included as one of their priority agenda and a resolution was passed to

that effect.
CASSA was invited by TINP - Madurai Branch, to extend consultancy in framing
training manual for 'Adolescent Girls’ .
After this sharing, discussion was initiated on the above. Clarification was sought for the

delay in passing the amended PNDT Bill in Parliament. Mr. Thomas George asked what
was the significant difference in the original Act and the amended Bill^As there was

commotion against Gujarat Violence and medical lobby was against amendments, the

amended Bill was not tabled before the parliament.

The significance is that the

amended bill stressed the total ban on preconception sex selection whereas doctors are
lobbying for regulation of preconception sex selection to avoid sex-linked disorders in the
offspring.

7

Ms Radha updated us with the information that the women were the carriers of sex

linked diseases and the sex linked diseases affect only the male offspring. The affected
couples can have a healthy girl child. So the demand of regulation of preconception sex

selection instead of ban is yet to be considered scientifically by CASSA. It was reiterated
to demand for total ban, as allowing x-y separation may be misused clinically by the
medical fraternity to meet the incessant demands of a people obsessed with the male
child, under the guise of ‘sex linked diseases’ and it is difficult to monitor.

Status of PNDT Act: and CASSA’s response - Impleading in the counter petition

filed against the writ petition filed by Indian Radiological and Imaging Association
in the Supreme Court of India:

The Supreme Court has so far passed seven interim orders in the writ petition filed by
CEHAT and others, for the enforcement of PNDT Act, directing the States to take efforts

for the enforcement and review the Act for necessary amendments. It is in this regard,
the convenor shared that it was brought to the knowledge of the CASSA that there are

three writ petitions pending before the Supreme Court, challenging the amendment

proposed in the draft amendment.

1. Writ petition by Dr Rajiv Bhatia Gurgaon, Haryana in the Supreme Court of India
with prayer to direct the competent authority to immediately grant registration to his
Ultrasound Clinic named “Dr Bhatia’s Diagnostix” and allowed to conduct his ethical

and legal ultrasound practice; to grant leave and liberty to use the portable
ultrasound machine.

2. PIL in the High Court of Delhi impugning the vires of Sec 2(d), 2(e), 2(l), 2(k), 3, 4, 5,
18, 29 of PNDT Act when applied to ultrasound clinics and routine ultrasounds for

fetal wellbeing and seeking a writ of mandamus and/or direction quashing the

provisions mention above when applied to ultrasound clinics and routine ultrasounds
for fetal well being as ultravires the provisions of Article 19, 20, 21 of the Constitution

of India.
3. Writ petition in the Supreme Court of India by Indian Radiological and Imaging
Association & Anr. against Union of India.

(Main highlights of the petition have

already been sent to all the members).
The main highlights of the writ petition mentioned in item No.3 were shared.

It was

decided by the members present that CASSA should implead in the case.

8

Discussion was then focussed on ‘how part of it’. There are two parts in this case. We
have counter our arguments both legally and medically.

Shared that Dr Sabu on behalf of CEHAT has impleaded in the case and his counsel is

Advo. Indira Jayasingh. The convenor shared the discussion with Dr Sabu regarding the
possibility of impleading in the case, on behalf of CASSA. CASSA requested Sabu to

find out an advocate in the Supreme Court.

He shared that the advocate fee alone

comes to approx. Rs.40000/- and the impleading petition should be drafted by CASSA.

He was willing to identify a suitable advocate.

Members also suggested some

advocates’ names, practicing in Supreme Court. (Members from Lawyers’ Collective,
Advo. M.C.Mehta, Advo Nalini).

It was also suggested that CASSA should seek the

support of legal / human rights institutions like People’s Watch, Goa Foundation.

Medical informations relevant to this case need to be updated.
some doctors.

Members suggested

(Doctors from CMC — Vellore, CHAI, Assistant Collector of

Kancheepuram, Dr Jayam of Kancheepuram, Dr Jayam of Chennai, Dr Indra of

Gandhigram, Dr Iyer - UNICEF team, Christian Institutions)

Doctors having experience it the field of gynaecology and handling ultrasound machine

will be identified for updating medical information related to the case, before preparing
the impleading petition.

Future activities of CASSA and strategies to strengthen the campaign:
It was felt that CASSA has focussed much on proactive strategy by way of organising

sensitisation and training programmes to different constituents of this issue and its
reactive intervention is minimal. Discussion was initiated to broad base the campaign

and to strengthen its activities.

After much deliberation, the group evolved the

followings.

Strategies should be evolved to take up the agenda of CASSA as agenda of
people’s movement.

CASSA has to work with women’s movements,

health

movements,

disability

movements, Women’s Development Corporation etc and sensitise them to incorporate
the agenda of CASSA as one of their priorities.

Evolve Programmes to motivate the doctors community to commit to the issue of
female feticide and to work with professional bodies like IMA and FOGSI.

9

Develop collaboration between health care professionals, media and NGOs to
combat this issue and to sustain the linkage by repeated exchange of ideas, opinions

and authentic information.
Strategy for the joint role of NGOs in creating public awareness on the issue of
declining child sex ratio and the need for enforcement of PNDT Act.
Mobilise political support to table the amended PNDT Bill in the Parliament in the

winter budget session.

Based on the evolved conception, the following programmes were planned:

Trainers Training Programme - One or two members from each district, who are
committed to this issue should be selected and suitably trained. They will in turn

carry out the training needs of different constituents, in their respective districts, with
the minima! support of CASSA.

Consultation with civic leaders - 20 members from each district, comprising
people from different sectors like academic, panchayat, medical, paramedical,

NGOs, media, human rights, student community, people’s organisation, judiciary will
be invited and an appeal will be made to enlist their support. Resource kit will be

given to them to strengthen their support work.
Sensitisation programmes to medical college students - Decided to carry out

this programme in all the medical colleges in Tamil Nadu, mainly for the final year
students of MBBS / post graduate students. It was shared that CASSA would co­
ordinate with HRF to convene such a programme in Chennai.

Media Advocacy - To make the issue of declining child sex ratio alive, a minimum of
four writers in print / electronic media in English and Tamil to be identified,

consistently work with the media to sustain the issue in the media by providing and
updating information to them.
Sensitisation programmes to the members of Appropriate Authority to make

them realise the implication of declining child sex ratio in the society and to motivate
them to enforce the PNDT Act with spirit.
District-level protest before the office of Joint Director of Health
Services - It was decided to organise this protest during the 16 days

“VIOLENCE ACTIVISM”, to oppose violence against women, between

November 25 and December 10, 2002. The purpose of the protest is to
demand the Appropriate Authority to curb the unethical promotion of

/o

sex determination centres in each district and to take stern action
against the violators. It was also decided to submit a memorandum to

the AA.

The kind of protest, strategy and the day of the protest may be

decided by the respective organisation volunteered to carry out the
protest in each district,

CASSA will send the model copy of the

handbill.

Organisations Volunteered are:

Name of the organisation

District

VRDP

Salem, Namakkal

SNEHA

Nagapattinam

Manitham

Ramnad, Sivagangai

SIRD

Madurai, Theni

CEDA

Dindigul

SIGA

Thiruvannamalai, Thiruvallur

LEAD

Trichy, Perambalur, Erode

TNVHA

Maximum districts

AREDS

Karur

AIDWA

To be confirmed

TNSF

To be confirmed

WC

To be confirmed

HRF

To be confirmed

Mobilising Funds:

To implead in the writ petition, it was decided to mobilise fund for the legal

expenses related to the case from the member organisations.

The members

present volunteered to contribute the following amount:
Organisation

Amount

LEAD

5000

VRDP

5000

Manitham

1000

EKTA

1000

SIGA

1000

II

NEYTHAL

2000

CEDA

5000

TNVHA

5000

It was decided to contact the other members over phone and generate fund for this

purpose.
Mr. Thomas gave a suggestion that CASSA ‘s main function should be that of Resource
Centre. CASSA should be equipped to extend all the technical support relevant to this
issue. CASSA should prepare a “Advocacy Kit” in both English and Tamil, in the form of
CD, transparent sheets, slides, documentary film, flip charts, handbills with all the

relevant ready reference material, to enable the different constituents to use it as a tool
to sensitise on this issue.

material is prepared.

UNICEF is willing to bring out the Advocacy Kit, once the

Mr. Thomas sketched the content of the Advocacy Kit and

promised to send guideline manual and the relevant information to CASSA, to prepare

the Advocacy Kit.

He also suggested to broadbase the campaign by inviting Ms Anuradha Rajivan,

Ms Jayashree, and Principal of Stella Mary’s College as members of the campaign.

Mr. Thomas also shared that UNICEF has released a grant of Rs.2,40,000/- to carry out
the education programmes for VHNs, Teachers and Doctors. It was decided to execute
these programmes in co-ordination with the member organisations by the end of January

2003.

*****

CAMPAIGN AGAINST SEX SELECTIVE ABORTION
tr'hMrfis: 11 f JCatnala 2nd Street, @huuut (diokkiknlam, JHadufai - 625 002.
<% Cfiax : 2530486& 2524762 e-mail:urdntdii.@ltoiniail.eowt
Chennai:
Qlaqnr, ddltle dlonnt, Saidapel, &tuinai 600 015.
<T)ho4ie'. 044 2353503 Cfaae: 2355905

1st December 2003.
Dear friends
Greetings. We are enclosing the minutes of the CASSA meeting held in Chennai on 24th
September 2003. We request you to suggest programmes which can be jointly

organised your organisation and CASSA, to sensitise the different constituencies.

More importantly, we need to monitor the functioning of the scan centres. If each of
your organisation is willing to spare one or two days, we can jointly pay a surprise

visit to the scan centres in your project area. We are planning to file the findings of

the monitoring visits to the Supreme Court for further actions.

As you are aware,

Dr Sabu will file this report on our behalf, as he is the member of Monitoring Committee,

empowered by the Supreme Court.

We are also enclosing a copy of the action plan evolved during the ‘State-level
Consultation for the Appropriate Authorities in Implementing the PNDT Act’ and

the final verdict of the Supreme Court, for your reference and necessary action. We
will appreciate your quick response, to expedite the pro-active role of CASSA.

Awaiting for your reply.

Warm regards
Yours sincerely

(P PHAVALAM)
Convenor
Encl:

Mmute*. of the mtfting.
cdefioH fdati of the eoeuitltation

Supreme @ourt final oereliet

AeV k'b ,

Minutes of the Campaign Committee Meet
held at Image, Chennai on 24th September 2003

The following members were present:
Mr A.Jesuraj - CEDA Trust, Dr Sabu M.George, MsK.Ranjitha & Ms R.Usha - VRDP,

Ms M.Rajeswari - Usilai Rural Workers Federation, Ms M.Jayanthi & Ms S.Anjammal -

SNEHA, Mr S.A.Kanagasabapathy - SSD, Mr M.Jeeva & Mr K.Maharajan - SIRD,
Ms Mina Swaminathan - MS Swaminathan Research Foundation, Ms M.Valli - SIGA,
Mr Nambi - CSED, Mr R.N.Varadhan - FEDCOT, Mr R.Sambath - WCWC, Mr Ossie
Fernandes & Ms M.Santhi - HRF, Ms Jesurethinam - LAW Trust, Ms A.Gandimathi,

Ms Meenakshi and Ms P.Phavalam.

Ms Girija Kumarababu - ICCW, Ms Gabriele - CSA, Mr Ramakant Satapathy - CLAP

expressed their leave of absence by their letters and Dr Vasanthi Devi over phone.
The convenor welcomed the members and facilitated the meeting.
Agenda of the Meeting:

■

Ratification of the minutes of the previous meeting

■

Review of CASSA’s activities since last meeting

■

Future Activities of CASSA

The proceedings of the state-level consultation for the implementing authorities of PNDT
Act, which took place in the morning was reviewed. It was unanimously decided to
monitor the execution of the ‘Action Plan’ proposed for Appropriate Authorities. (A copy

of the proposed Action Plan is enclosed). It was also decided to convene a state-level
workshop to review the enforcement of MTP Act and its implications on sex-selective

abortions and sensitisation programmes for judicial officers and media personnel.

Agenda No.1:

The minutes of the last meeting was ratified by the members present.
Agenda No. 2:

Review of CASSA’s activities since last meeting:

The convenor shared the activities of CASSA since last meeting.

■

CASSA submitted a memorandum to the Chief Minister of Tamil Nadu, Central
Ministry of Health and Family Welfare and MPs of Tamil Nadu, highlighting the

declining trend in child sex ratio and demanding need for amending the PNDT
Act 1994, which was already tabled before the parliament for approval.

The

core-team of CASSA met Mr Mohan, M.P. and requested him to expedite the
process of enacting the amendment in the PNDT Act.

■

During the last meet, it was decided to launch a token protest in the districts of
member organisations.

SIGA - Thiruvallur District, VRDP - Salem District,

SNEHA - Nagapattinam, LEAD - Erode District and Trichy District organised
protests and submitted memorandum to the Joint Directors of Health Services in

their respective districts.
■

Regarding CASSA’s decision to implead in the petition against the PIL by IRIA,
the legal expenses were shared among SIRD, VRDP, PREPARE and SIGA.
CASSA being an unregistered body, SIRD was the petitioner and senior counsel
of Supreme Court Mr Collin Gonsalves filed the impleading petition. As the case
was withdrawn by IRIA, the petition was dismissed.

■

CASSA organised the following programmes:

o

State-level Consultation on the role of doctors in effective enforcement of
PNDT Act in the month of April 2003. This programme was sponsored

by British High Commission.

This programme was attended by senior

medical practitioners such as sonologists, gynaecologists, office bearers

of IMA, Tamil Nadu Medical Council, FOGSI - TN and Director of Medical
and Rural Health Services and members of CASSA.

The programme

ended up with the declaration of doctors, titled as ‘Chennai Declaration’

and this is yet to be published.

o

CASSA organised a state-level consultation with the leaders of mass
organisations, trade unions, child rights organisaions, women’s rights
organisaitons, human rights organisations, disability movement, health

movement, and leaders of panchayat raj institutions. The purpose of this
consultation is to broadbase the campaign and to transcend the mission

of CASSA as the priority agenda of the participating organisation. The
resolutions evolved during this meeting was sent to the participating
members and members of CASSA.

o

CASSA organised district level consultations with the VHNs and Medical
Officers of Madurai, Theni, Namakkal and Perambalur Districts to review

their role in addressing the issue of declining child sex ratio and evolve
strategies to address the same.

The ‘Action Plan’ evolved during the

consultation is yet to be presented before the Director of Public Health

and Preventive Medicine.
o

CASSA organised district-level consultation for the Medical Officers of
Erode and Salem Districts to review their role in addressing the issue of
declining child sex ratio and evolve strategies to address the same.

Activities carried out:
■

The convenor was invited as resource person to a training programme for the
students of Law on human rights intervention, organised by People’s Watch in

Dindigul and gave inputs on “Salient Features of PNDT Act” in addressing the

issue of female feticide.
■

CASSA filed a complaint letter with the Central Ministry of Health and Family

Welfare seeking action against the pharmacy company ‘Genowonderkit’ for its
advertisement in the internet (www.sandhyapharma.com).

■

CLAP, a legal rights organisation based in Orissa has filed a PIL against
advertisement on ‘Gen-select’ in the internet. CASSA attempted to implead in

the PIL. Supreme Court dissolved the CLAP’S petition, as the amendment in
PNDT Act has brought the ‘internet’ into the ambit of the Act.

■

CASSA has sent all the reading materials to Plan International, which is planning

to bring out a dossier/resource kit for the campaigners against declining child sex

ratio.
■

CASSA brought out posters on salient features of PNDT Act with the latest
amendments.

■

CASSA appealed to the Director of School Education to include the views of the
training manual for adolescent girls, published by CASSA, in the content of the

new subjects on ‘health and hygiene’ to be introduced for High Schools and

Higher Secondary Schools.

■

CASSA also submitted a memorandum to NAWO, to include ‘at birth sex ratio’
and ‘infant mortality rate - gender differential’ as health indicators, while

consolidating the status report of India for CEDAW.

■

CASSA is in the monitoring committee on female infanticide constituted by
district administration of Madurai.

CASSA’s intervention that sex selective

abortions contribute more to the declining child sex ratio gave new insights

■

Motion Magazine is a multicultural, online US publication about democracy with
several sections in defence of affirmative actions It has a leadership of 220000

month. The publisher and co-editor Nic Paget Clarke interviewed the convenor
and core-team members and the write-up on implications of declining child sex
ratio and role of CASSA will be soon published in the online publication

<http://www.inmotionmagazine.com>.

■

The convenor extended training inputs to the RCH members of TNVHA on “The
salient features of PNDT Act and the strategies for effective enforcement of the

Act” in Trichy.

■

TNVHA, a member organisation of CASSA convened a state-level workshop on

“implementation

of

PNDT Act” on 9th January 2003.

The convenor and

Ms Gandimathi participated as resource team.
■

CASSA has sent letters to multinational manufacturing companies of imaging
technologies, seeking information about the number of centres to whom they

have sold the technologies for the past three years.
■

CASSA was invited to extend thematic inputs on “Role of Doctors in

implementing PNDT Act”, for the Medical Officers under medical education

programme, organised by Joint Director of Health Services - Theni on 27th
January 2003.
■

CASSA was invited to facilitate a session on implication of declining child sex
ratio and PNDT Act, to the sangam members of PEARL Trust, Paramakudi.

■

CASSA advocated for the withdrawal of Section 302, against the alleged victims

of female infanticide and also highlighted the implications of punitive action on
the victimised family members, especially the children, during the state-level

convention organised by Campaign Against Female Infanticide.
Agenda No. 3 - Future Activities of CASSA:

After deliberation, it was decided to carry out the following activities.
1. CASSA in co-ordination with DPH and DMS should convene a state-level

consultation with the Department of Family Welfare, for the effective
implementation of MTP Act.

2. In order to broad base the campaign, and to transcend the mission of CASSA as
a priority agenda of NGOs, a trainers’ training programme will be organised by
CASSA.

3. Supreme] in its final judgment in the writ petition No.301/2000, has extended the
functioning of UTejTpnLtoring„cpmmittee for one more year.

Using this

opportunity, Dr Sabu being the member in the Monitoring Committee will be

invited to visit the scan centres, in coordination with the member organisations in
different districts.
4. Since the inception of the campaign, CASSA has been playing the lead role in

sensitising different constituencies: VHNs, Adolescent Girls, Medical Personnel,
Panchayat Presidents, Teachers and Media personnel. It is high time that the

programme initiative of CASSA should be transferred to member organisations.

On this request, CEDA of Dindigul, SIGA of Thiruvallore, SNEHA of

Naqapattinam, ACCESS of Chennai, CSED of Coimbatore, VRDP of Salem,
WCWC of Mettur and HRF of Chennai

have consented to organise

sensitisation programme to different constituencies.

5. The suggestion to organise a residential media workshop for the senior medial
personnel / potential journalists, put forward by UNICEF was deliberated.
ACCESS came forward to convene a workshop on ‘Alternative Media’ in
coordination with CASSA.

6. CASSA was invited by VIMOCHANA to convene a workshop on “Declining Child
Sex Ratio”, in the forth coming WSF to be convened from 16th to 20th January
2004. CASSA has expressed its willingness provided the workshop is organised

under the banner of CASSA. A planning meeting will be held in this regard in the
month of December, to decide on the strategies of convening this workshop.

*****

THE ACCEPTED CONCRETE ACTION PLAN EVOLVED
AT THE END OP THE STATE-LEVEL CONSULTATION ON

ROLE OE APPROPRIATE AUTHORITIES IN IMPLEMENTING OP PNDT ACT,

IN CHENNAI ON 24™ SEPTEMBER 2003
o

Wide publicity to be continued against sex selection, sex determination and PNDT
Act through print and electronic media, like polio plus campaign, till there is no
discrimination between boys and girls.

o

Registration of pre-natal diagnostic centres at the district level as per the directions
of the Supreme Court, to avoid procedural delay.

0

Constitution of Advisory Committees at the district level to assist and advise the

Appropriate Authority to discharge its functions and convening the meeting of the
advisory committee once in two months.

o

Compulsorily seeking the advice of the advisory committee while processing the

application for registration and investigating the complaint for suspension or
cancellation of registration.
0

Strictly follow the mandatory procedure prescribed under Sec 19 of the Act before
granting certificate of registration to any person or organisation using the ultrasound

machines/imaging technologies.
0

Publishing the list of the advisory committee members by the Appropriate Authority,

for the information of the public.
0

Registration of GCC/GC/GL/Ultrasound Clinic/lmaging Centre independently under

each category and publishing periodically the lists of registered GCC, GL, GC,

Ultrasound Clinics and Imaging Centres by the Appropriate Authority.
0

Search, seize documents, records, objects, etc., of unregistered bodies under
Section 30 of the Act.

0

Taking legal action against sex determination and sex disclosure, as a deterrent

measure, though difficult to prove.
o

Sex determination and sex disclosure alone are not violations. Stern action against
all violations particularly for non-maintenance of records, advertisement, non­
registration, sale of machine to the unregistered centres etc., with an immediate

effect.
0

Publishing the consolidated status report on enforcement of the Act, activities of

different enforcement bodies, activities undertaken

to create public awareness,

complaints received, action taken, legal status of the case etc., periodically for the

public.
0

Access of records maintained by different bodies constituted under the Act to the
public, as mentioned in the final order of the Supreme Court

0

Constitution of monitoring committee at the district level comprising District Collector,

District Judge, Commissioner of Police and Joint Director of Health Services to

ensure the support of the different administrative wings for the effective enforcement

of the Act.

The district appropriate authority may take steps to constitute this

committee.
0

Obtaining information about the users of the ultrasound machines / scanners from

the manufacturers of Ultra Sound Machines, Indian Medical Association, Indian
Radiologists Association, Federation of Obstetrics and Gynaecologists Society of

India (FOGSI), by Appropriate Authority to bring all the scan centres under PNDT
Act.

o

Taking

urgent

steps

to

constitute

the

State

Supervisory

Board

and

Multi Member Appropriate Authority at State Level as mentioned in the Amended act,

as Supreme Court in its final order mentioned that Tamil Nadu is one of the few
states which have not constituted the above bodies.
o

Ensure the nomination of 3 eminent social workers in the State Advisory Committee,

one of whom shall be a women activist, as the present State Advisory Committee
does not have representation for social workers.

o

Distribution of fund to district level to strengthen the monitoring mechanism, widening

propaganda by issuing periodical advertisements and various directions regarding
the PNDT Act and Supreme Court Directions and to create awareness to the public.

o

Suo

moto

investigation

against

violations

such

as

advertisement

on

sex

determination and sex selection, non-maintenance of records required under PNDT

Act, disclosure of sex through oral communication, non-maintenance of records of

abortions required under MTP Act, etc.

o

The time limit to process the registration application and issuing certificate should be
strictly followed as mentioned in the rules.

o

Action for the early enactment of “Tamil Nadu Private Clinic Establishment Act”

o

Organising a Joint meeting of Appropriate Authorities under the PNDT Act, District

Magistrates, Public Prosecutors and Police to enable effective implementation

0

Ensuring the registration of all mobile scan units within 30 days, failing which the

activities of these scan centres to be stopped.
0

Taking legal actions against violators - The Appropriate Authority through MCI
should periodically publish the data on the status of various actions taken by the

Appropriate Authority against the violators - including the progress of prosecution

proceeding in cases filed.
0

Organising sensitisation programmes to the judges, public prosecutors, police
personnel, sonologists and radiologists on the PNDT Act.

0

Meeting of appropriate authorities of State and Districts once in 6 months to review

the enforcement and strengthen the enforcement mechanisms.
0

Preparation of common report format to maintain uniformity and easy consolidation.

0

Initiating dialogue to arrive at consensus to bring all the referral doctors into the fold

of PNDT Act, to achieve the purpose of the Act.
0

Seeking the advise of Central Government / Supreme Court to define the term

‘genetic counselling’.
0

Initiating dialogue to arrive at consensus on limiting the number of scan centres in

each district, proportionate to the percentage of disability of new borns and
population of the district.

Medical Termination of Pregnancy Act 1971:
0

Strict maintenance of all the records under MTP Act by the approved clinics.

0

Recording of the gender of the fetus aborted during second and third trimester

abortions.
0

Stern legal actions against persons other than medical practitioners indulging in

termination of pregnancy.
0

Review the legalisation of non-invasive abortion pill, and prevent the availability of
abortion pill in the medical shop without doctor’s prescription, as there is wider scope

for misuse to eliminate female fetuses.
0

Displaying prominently, the list of medical practitioners and hospitals registered

under MTP Act, in all PHCs, private hospitals and other public places.

35

2003(7) SCALE
CENTRE FOR ENQUIRY INTO HEALTH
AND ALLIED THEMES (CEHAT) & OTHERS
VS
UNION OF INDIA & OTHERS
CORAM: M.B. SHAH AND ASHOK BHAN, JJ.

345
(

Petitioners
Respondents 40

PUBLIC INTEREST LITIGATION — FEMALE FOETICIDE — PRE-NATAL DIAGNOSTIC
TECHNIQUES (REGULATION AND PREVENTION OF MISUSE) ACT, 1994 [NOW
Judgment dated September 10, 2003 in W.P. (C) No. 301 of 2000.

)

45

346

CEHATvs U.O.I. (Shah, J.)

KNOWN AO THE PRE-CONCEPTION AND PRE-NATAL DIAGNOSTIC TECHNIQUES
(PROHIBITION OF SEX SELECTION) ACT] — SECTION 23, 28 & 30 — Nonimplementation of orders of this Court — Duty of the Union Government as well
as the State Governments and UTs to implement the same as early as possible —
5 Disposing the petition Court orders compliance of its earlier orders and issues further
directions to the Central Government/State Govemments/UTs.

Shah, J.— It is admitted fact that in
Indian Society, discrimination against girl
10 child still prevails, may be because of
prevailing uncontrolled dowry system despite
the Dowry Prohibition Act, as there is no
change in the mind-set or also because of
insufficient education and/or tradition of
15 women being confined to household
activities. Sex selection/sex determination
further adds to this adversity. It is also known
that number of persons condemn
discrimination against women in all its forms,
20 and agree to pursue, by appropriate means, a
policy of eliminating discrimination against
women, still however, we are not in a position
to change mental set-up which favours a male
child against a female. Advance technology
25 is increasingly used for removal of foetus
(may or may not be seen as commission of
‘murder) but it certainly affects the sex ratio.
The misuse of modem science and technology
by preventing the birth of girl child by sex
30 determination before birth and thereafter
abortion is evident from the’2001 Census
figures which reveal greater decline in sex
ratio in the 0-6 age group in States like
Haryana, Punjab, Maharashtra and Gujarat,
35 which are economically better off.
2. Despite this, it is unfortunate that law
which aims at preventing such practice is not
implemented
and, therefore, NonGovernmental Organisations are required to
40 approach this Court for implementation of the
Pre-natal Diagnostic Techniques (Regulation
and Prevention of Misuse) Act, 1994 renamed
after amendment as “The Pre-conception and
Pre-natal Diagnostic
Techniques
45 (Prohibition of Sex Selection) Actn

(hereinafter referred to as 'the PNDT Act’)
which is the normal function of the Executive
3. In this petition, it was inter alia prayed
that as the Pre-natal Diagnostic Techniques
contravene the provisions of the PNDT Act,
the Central Government and the State
Governments be directed to implement the
provisions ofthe PNDT Act (a) by appointing
appropriate authorities at State and District
levels and the Advisory Committees; (b) the
Central Government be directed to ensure that
Central Supervisory Board meets every 6
months as provided under the PNDT Act; and
(c) for banning of all advertisements of pre­
natal sex selection including all other sex
determination techniques which can be
abused to selectively produce only boys either
before or during pregnancy.
4. After filing of this petition, notices
were issued and thereafter various orders from
time to time were passed to see that the Act
is effectively implemented.
A] On 4th May 2001, following order was
passed:“It is unfortunate that for one reason or
the other, the practice of female
infanticide still prevails despite the fact
that gentle touch of a daughter and her
voice has soothing effect on the parents.
One of the reasons may be the marriage
problems faced by the parents coupled
with the dowry demand by the so-called
educated and/or rich persons who are
well placed in the society. The traditional
system of female infanticide whereby
female baby was done away with after
birth by poisoning or letting her choke
on husk continues in a different form by

)

/

CEHATvs U.O.I. (Shah, J.)

taking advantage of advance medical
techniques. Unfortunately, developed
medical science is misused to get rid of
a girl child before birth. Knowing foil
well that it is immoral and unethical as
well as it may amount to an offence,
foetus of a girl child is aborted by
qualified and unqualified doctors or
compounders. This has affected overall
sex ratio in various States where female
infanticide is prevailing without any
hindrance.
For controlling the situation, the
Parliament in its wisdom enacted the Pre­
natal Diagnostic Techniques (Regulation
and Prevention of Misuse) Act, 1994
(hereinafter referred to as “the PNDT
Act”). The Preamble, inter alia, provides
that the object of the Act is to prevent
the misuse of such techniques for the
purpose of pre-natal sex determination
leading to female foeticide and for
matters connected therewith or incidental
thereto. The Act came into force from
1st January, 1996.
It is apparent that to a large extent, the
PNDT Act is not implemented by the
Central Government or by the State
Governments. Hence, the petitioners are
required to approach this Court under
Article 32 of the Constitution of India.
One of the petitioners is the Centre for
Enquiry Into Health and Allied Themes
(CEHAT) which is a research center of
Anusandhan Trust based in Pune and
Mumbai. Second petitioner is Mahila
Sarvangeen Utkarsh Mandal (MASUM)
based in Pune and Maharashtra and the
third petitioner is Dr. Sabu M. Georges
who is having experience and technical
knowledge in the field. After filing ofthis
petition, this Court issued notices to the
concerned parties on 9.5.2000. It took
nearly one year for the various States to
file their affidavits in reply/written

347

submissions. Primafacie it appears that
despite the PNDT Act being enacted by
the Parliament five years back, neither
the State Governments nor the Central
Government has taken- appropriate 5
actions for its implementation. Hence,
after considering the respective
submissions made at the time of hearing
of this matter, as suggested by the learned
Attorney General for India, Mr. Soli J. 10
Sorabjee following directions are issued
on the basis of various provisions for the
proper implementation of the PNDT
Act:I. Directions to the Central 15
Government
1. The Central Government is
directed to create public
awareness against the practice
of pre-natal determination of 20
sex and female foeticide
through appropriate releases/
programmes in the electronic
media. This shall also be done
by Central Supervisory Board 25
(“CSB” for short) as provided
under Section 16(iii) of the
PNDT Act.
2. The' Central Government is
directed to implement with all 30
vigor and zeal the PNDT Act
and the Rules framed in 1996.
Rule 15 provides that the
intervening period between two
meetings of the Advisory 35
Committees constituted under
sub-section (5) of Section 17 of
the PNDT Act to advise the
appropriate authority shall not
exceed 60 days. It would be seen 40
that this Rule is strictly adhered
to.
n. Directions to the Centrall
Supervisory Board (CSB)
1. Meetings of the CSB will be 45

348

5

10

15

20

25

30

35

40

45

CEHATvs U.O.I. (Shah, J.)
held at least once in six months.
[Re. Proviso to Section 9(1)].
The Constitution of the CSB is
provided under Section 7. It
empowers
the
Central
Government to appoint ten
members under Section 7(2)(e)
which includes eminent medical
practitioners including eminent
social
scientists
and
representatives of women
welfare organizations. We hope
that this power will be exercised
so as to include those persons
who can genuinely spare some
time for implementation of the
Act.
2. The CSB shall review and .
monitor the implementation of
the Act. [Re. Section 16(ii)].
3. The CSB shall issue directions to all
State/UT Appropriate Authorities to
furnish quarterly returns to the CSB
giving
a
report
on
the
implementation and working of ±e
Act. These returns should inter alia
contain specific information about:(i) Survey of bodies specified
in section 3 of the Act.
(ii) Registration of bodies
specified in section 3 of the
Act.
(iii) Action taken against non­
registered bodies operating
in violation of section 3 of
the Act, inclusive of search
and seizure of records.
(iv) Complaints received by the
Appropriate Authorities
under the Act and action
taken pursuant thereto.
(v) Number and nature of
awareness
campaigns
conducted and results
flowing therefrom.

4.

The CSB shall examine the
necessity to amend the Act
keeping in mind emerging
technologies and difficulties
encountered in implementation
of the Act and to make
recommendations to the Central
Government. [Re. Section 16]
5. The CSB shall lay down a code
of conduct under section 16(iv)
of the Act to be observed by
persons working in bodies
specified therein and to ensure
its publication so that public at
large can know about it.
6. The CSB will require medical
professional bodies/associations
to create awareness against the
practice
of
pre-natal
determination of sex and female
foeticide and to ensure
implementation of the Act.
HL Directions to State Governments/
UT Administrations
1. All State Governments/UT
Administrations are directed to
appoint by notification, fully
empowered
Appropriate
Authorities at district and sub­
district levels and also Advisory
Committees to aid and advise
the Appropriate Authority in
discharge of its functions [Re.
Section 17(5)]. For the Advisory
Committee also, it is hoped that
members of the said Committee
as provided under section
17(6Xd) should be such persons
who can devote some time for
the work assigned to them.
2. All State Governments/UT
Administrations are directed to
publish a list ofthe Appropriate
Authorities in the print and
electronic media in its

(

(

CEHATvs U.O.I. (Shah, J.)

respective State/UT.
All State Govemments/UT
Administrations are directed to
create public awareness against
the practice of pre-natal
determination of sex and female
foeticide through advertisement
in the print and electronic media
by hoardings and other
appropriate means.
4. All State Govemments/UT
Administrations are directed to
ensure that all State/UT
Appropriate Authorities furnish
quarterly returns to the CSB
giving a report on the
implementation and working of
the Act. These returns should
inter alia contain specific
information about:(i) Survey of bodies specified
in section 3 of the Act.
(ii) Registration of bodies
specified in section 3 of the
Act
(iii) Action taken against non­
registered bodies operating
in violation of section 3 of
the Act, inclusive of search
and seizure of records.
(iv) Complaints received by the
Appropriate Authorities
under the Act and action
taken pursuant thereto.
(v) Number and nature of
awareness
campaigns
conducted and results
flowing therefrom.
IV. Directions
to
Appropriate
Authorities
1. Appropriate Authorities are
directed to take prompt action
against any person or body who
issues or causes to be issued any
advertisement in violation of

3.

J

349

section 22 of the Act.
Appropriate Authorities are
directed to take prompt action
against all bodies specified in
section 3 of the Act as also 5
against persons who are
operating without a valid
certificate of registration under
the Act.
3. All State/UT Appropriate 10
Authorities are directed to
furnish quarterly returns to the
CSB giving a report on the
implementation and working of
the Act. These returns should 15
inter alia contain specific
information about:(i) Survey of bodies specified
in section 3 of the Act.
(ii) Registration of bodies 20
specified in section 3 of the
Act including bodies using
ultrasound machines.
(iii) Action taken against non­
registered bodies, operating 25
in violation of section 3 of
the Act, inclusive of search
and seizure of records.
(iv) Complaints received by the
Appropriate Authorities 30
under the Act and action
taken pursuant thereto.
(v) Number and nature of
awareness
campaigns
conducted and results '35
flowing therefrom.
The CSB and the State Governments/
Union Territories are directed to report
to this Court on or before 30th July 2001.
List the matter on 6.8.2001 for further 40
directions at the bottom of the list.”
B] Inspite of the above order, certain States/
UTs did not file their affidavits. Matter was
adjourned from time to time and on 19th
September, 2001, following order was 45

2.

CEHATvs U.O.l. (Shah, J.)
(Regulation and Prevention of Misuse)
passed
Act, 1994 (hereinafter referred to as “the
“Heard the learned counsel for the parties
Act”). Hence it is directed that the
and considered the affidavits filed on
quarterly returns to Central Supervisory
behalf of various States. From the said
Board should be submitted giving the
affidavits, it appears that the directions
5
following information:issued by this Court are not complied
(a) Survey of Centres, Laboratories/
with.
Clinics,
1. At the outset, we may state that there
(b)
Registration of these bodies,
is total slackness by the Administration
(c) Action taken against unregistered
in implementing the Act. Some learned
10
bodies,
counsel pointed out that even though the
(d)
Search and Seizure,
Genetic Counselling Centre, Genetic
(e)
Number
of awareness campaigns,
Laboratories or Genetic Clinics are not
and
registered, no action is taken as provided
(f)
Results
of campaigns”
under Section 23 of the Act, but only a
15
C]
On
7th
November,
2001, learned counsel
warning is issued. In oUr view, those
for
the
Union
of
India
stated that the Central
Centres which are not registered are
Government has decided to take concrete
required to be prosecuted by the
steps for the implementation of the Act and
Authorities under the provisions of the
suggested to set up National Inspection and
Act and there is no question of issue of
20
Monitoring
Committee
for
the
warning and to permit them to continue
implementation
of
the
Act.
It
was
ordered
their illegal activities.
accordingly.
It is to be stated that the Appropriate
D] On 11th September, 2001, it was pointed
Authorities or any officer of the Central
out that certain State Governments have not
or the State Government authorised in
25
disclosed the names of the members of the
this behalf is required to file complaint
Advisory Committee. Consequently, the State
under Section 28 of the Act for
Governments were directed to publish the
prosecuting the offenders.
names of advisory committee in various
Further wherever at District Level,
districts so that if there is any complaint, any
appropriate authorities are appointed,
30
citizen can approach them. The Court further
they must carry out the necessary survey
observed thus:of Clinics and take appropriate action in
“For implementation of the Act and the
case of non-registration or nonrules, it appears that it would be desirable
compliance of the statutory provisions
if the Central Government frames
including the Rules. Appropriate
35
appropriate
rules with regard to sale of
authorities are not only empowered to
ultrasound
machines
to various clinics
take criminal action, but to search and
and
issue
directions
not
to sell machines
seize documents, records, objects etc. of
to unregistered clinics. Learned counsel
unregistered bodies under Section 30 of
Mr. Mahajan appearing for Union of
the Act.
40
India submitted that appropriate action
2. It has been pointed out that the State/
would be taken in this direction as early
Union Territories have not submitted
as possible.”
quarterly returns to the Central
E] On March 31, 2003, it was pointed out
Supervisory Board on implementation of
that in conformity with the various directions >
the Pre-Natal Diagnostic Techniques
45
350

CEHATvs U.O.I. (Shah, J.)
35I
issued by this Court, the Act has been
4) Complaints received and action
amended and titled as "The Pre-conception1
'
taken pursuant thereto.
and Pre-natal Diagnostic Techniques
5) Natureand number ofawarenless
(Prohibition of Sex Selection) Act". It was
programmes.
submitted that people are not aware of the
6) Direct that the Central 5
new amendment and, therefore, following
Supervisory Board shall carry
reliefs were sought:out all the additional functions
a) direct the Union of India, State
as
given under the amended
Governments/UTs
and
the
Section
16 of the Act, in
authorities constituted under the
particular, to oversee the 10
PNDT Act to prohibit sex selection
performance
of various bodies
techniques and its advertisement
constituted
under
the Act and
throughout the country;
take
appropriate
steps
to ensure
b) direct that the appropriate authorities
its
proper
and
effective
shall also include “vehicles” with
implementation.
ultra sound machines etc., in their
As against this, Mr. Mahajan learned '
quarterly reports hereinafter as
counsel appearing for the Union of India
defined under Section 2(d);
submits
that on the basis of the aforesaid
c) any person or institution selling Ultra
amendment, appropriate action has
Sound machine should provide
already been taken by Union of India for 20
information to the appropriate State
implementation and almost all State
Authority in furtherance of Section
Govemments/UTs
are informed to
3-B of the Amended Act;
implement
the
said
Act
and the Rules and
d) direct that State Supervisory Boards
the State Govemments/UTs are directed
be constituted in accordance with the
to submit their quarterly report to the 25
amended Section 16A in order to
Central Supervisory Board.
carry out the functions enumerated
Considering
the amendment in the Act,
therein;
in our view, it is the duty of the Union
e) direct appropriate authorities to
Government as well as the State
initiate suo moto legal action under
Govemments/UTs to implement the 30
the amended Section 17(iv)(e);
same as early as possible”
f) direct that the Central Supervisory
FJ At the time of hearing, learned counsel for
Board shall publish half yearly
the petitioners submitted that appropriate
consolidated reports based on the
directions including the steps which are
quarterly reports obtained from the
required to be taken on the basis of PNDT 55
State bodies. These reports should
Act and the suggestion as given in the written
specifically contain information on:
submission be issued.
1) Survey of bodies and the number
5. On this aspect, learned counsel for the
of bodies registered.
parties were heard.
2) Functioning of the regulatory
6. In view of the various directions issued 40
bodies providing the number
by this Court as quoted above, no further
and dates of meetings held.
directions are required except that the
3) Action taken against non­
directions issued by this Court on 4th May,
registered bodies inclusive of
2001, 7th November, 2001, 11th December’
search and seizure of records.
2001 and 31st March, 2003 should be 45

(

t*

352

Thirumala Tirupati Devasthanams vs T Ananthacharyulu (Variava, J.)

complied with. The Central Government/
State Govemments/UTs are further directed
that:*
a) For effective implementation of the
5
Act, information should be published
by way of advertisements as well as
on electronic media. This process
should be continued till there is
awareness in public that there should
10
not be any discrimination between
male and female child.
b) Quarterly reports by the appropriate
authority, which are submitted to the
Supervisory Board should be
15
consolidated and published annually
for information of the public at large.
c) Appropriate
authorities
shall
maintain the records of all the
meetings
of
the
Advisory
20
Committees.
d) The National Monitoring and
Inspection Committee constituted by
the Central Government for
conducting periodic inspection shall
25
continue to function till the Act is
effectively implemented. The reports
of this Committee be placed before
the Central Supervisory Board and
State Supervisory Board for any

further action.
e) As provided under Rule 17(3), public
would have access to the records
maintained by different bodies
constituted under the Act.
f) Central Supervisory Board would
ensure that the following States
appoint the state Supervisory Board
as per the requirement of Section
16A.
1. Delhi 2. Himachal Pradesh 3.
Tamil Nadu 4. Tripura 5. Uttar
Pradesh.
g) As per requirement of Section
17(3)(a), the Central Supervisory
Board would- ensure that the
following States appoint the multi­
member appropriate authorities:
1. Jharkhand 2. Maharashtra 3.
Tripura 4. Tamil Nadu 5. Uttar
Pradesh.
7. It will be open to the parties to
approach this Court in case of any difficulty
in implementing the aforesaid directions.
8. The Writ Petition is disposed of
accordingly.
9. In view ofthe aforesaid order, pending
lAs have become infructuous and are
disposed of accordingly.

30

V'

Page 1 of 3

Main Identity
From:

To:
Cc:
Sent:
Attach:
Subject:

“sudha tewari" <sudha_iewari@mantraoniine.com >
"cehat" <cehat@vsnl.com>
<guptarn@hotmaiI.com>, <visaria@vsnl.com>; <stm@del2.vsnl. net. in>;
<sochara@bir.vsnl.net. in*; <pads7S@yahoo. com*; <masumfp@vsnl.com*;
<iyengars@icenet.net >; <kambacc@vsnl.com>; <healthwatch@vsnl.com >
Monday. September 22, 2003 4:45 PM
COMMENTS ON DRAFT POLICY PAPER ON ABORTION.doc
Fw: policy paper on abortion

---- Original Message----From: sudha tcwaii <sudha_tcwari@mantraonline, com>
To: cehat <cehat@vsnl. com>
Cc: <guptam@hotmail.com>: <visaria@vsnl.com>: <stm@del2.vsnl.net,in>:
<sochara@bir.vsni.net.in>; <pads78@yahoo.com>; <masumfp@vsni.com>;
<iyengars@icenet.nel>; <kambacc@vsnl.eom>: <acmh2@nb.mc.in>:
<rvimala@vsnl.com>. <liealtliwatch@vsnl.com >
Sent- Monday, September 22; 2003 4:40 PM
Subject: Re: policy paper on abortion

> Subject : Policy Paper on Abortion
> Dear Ravi,
> It was a pleasure to go through the draft of the policy paper on abortion,
> prepared by Siddhi. First oi ail, I wish to congratulate Siddhi for an
> excellent overview and for covering each of the aspect well. I am happy to
> enclose my comments/ suggestions Its rather long, but I feel are very
> important for our review. I therefore, look forward to their being
> incorporated in the paper.
>

> Since Cehat has been so pro-active in the area of safe abortion, I wish to
> take this opportunity to brief you regarding a legal case being faced by
us
> on registration of one of our clinics in Delhi. Instead of further
> simplifying the registration process, it has now been made verv cumbersome
> in Delhi, and its possible that as a result of Delhi Court ruling such a
> situation would arise in other cities also.
>

Our integrated reproductive health clinic in a semi-commercial area
> (although designated as residential area) Lajpatnagar had been registered
as
* “
> an MTP clinic bv the Directorate of Family Welfare, NOT of Delhi in 2001,
> but just before this, the Resident Welfare Association filed a writ in
the
> High Court of Delhi to restram PSS from opening/ granting permission for
a
> M I P Clinic, (our clients are mainly from lower economic status and rarely
> have cars and that we work only on an OPD basis, 9am to 5 pm.).
> Subsequently, the Association amended its writ seeking quashing of
certificate granted. In the meanwhile, DDA has allowed Nursing Homes in

<5^

autta-a

G

IP

/</

Q^i 2

9/23/03

Page 2 of 3

r > residential areas, provided some basic conditions were fulfilled. As you
are
> aware a Clinic functions on a much lower level than a Nursing Home and
both
> cannot be grouped in one category
> 1 he judge has now given general directions that DDA and MCD would
henceforth
<
> issue; no objection certificates ( basis and requirement not known), only
> after which the
re Department would process the application as
> per the MTP Act and Rules. They have asked FW department to ensure that
all
> existing registered MTP Clinics and Nursing Home go through this process.
> PSS has been further singled out tor this particular clinic and asked to
> obtain no objection from the concerned authorities and then communicate to
> FW Department. As you are aware, getting such no objections from
Government
> Departments is not only lime- consuming but also expensive.

> Its obvious that instead of making the registration process simpler ( as
per
> the Population 2000 Policy and the amended Act and Rules), additional
> barriers are Being introduced which will make it virtually impossible to
now
> register clinics. Instead of "facilitating" the entire process, the
> control" aspect is further setting in. Is it that only for abortions that
> approval of clinic is necessary? What about other consultations and OPD
> procedures? For example, for steniizaiion procedure, those with
sonography.
> imaging centers, infertility clinics, fiaclurc clinics, such a
registration
> is not ncccssaiyr. Just because there is an MTP Act, we arc being pulled
in,
> instead of further streamlining the process to facilitate the process. The
> modified MTP ACT and Rules <ue now more realistic, on which other
> requirements are being imposed, Is the MTP Act governed or to follow
other
> acts?
> Above all, it limits access to legal abortion services; its an issue of
> denying women the right to safe and legal abortions. Tn particular, those
> most at disadvantage will suffer the most. Such a situation will result in
> higher malemal mortality and morbidity, which is already loo high in our
> country and verxz little reductions, has been possible so far.
> We are filing an appeal and are also trying to persuade the h W Dept to do
> the same. However, the Government, although upset, so far are unwilling to
> take up this issue with the courts. Do you not feel that this case must be
> taken up as Public Interest Litigation? If yes, wzould Cehat be
interested?
> Please let me know your reactions and suggestions; 1 would then send vou
all
> details of the case.

9/23/03
Page 3 of 3

> I look forward to hearing from you
>

> Warm Regards
> Sudha
> ---- Original Message----> From: cchat <cchat@vsnl.com>
> To: RAVLNDRA GUP TA <guptam@hotmail.com >: visaria <visaria@vsnl. com>
> Cc: dr saramma thomas mathai <stm@del2.vsnl.net.in>; dr Thelma Narayan
> <sochara@blr. vsnl.net.in>. Padmini Swaminathan <pads78@vahoo.com>;
> ManishaGupte <masumfp@vTsnl.com>; Sudarshan Iyengar <iyengars@icenet.net>;
> sudhatewari <sudha tcwari@niantraonline.com>:; Kamini Rao
<kambac^A^nLcom>;
> narika namshum <acmh2@nb.nic.in>; <r\yimala@rvsnl.com>;
<hcal iiiwaicii@yjsi u. coi n>
> Sent: Monday, September 08,2003 5:07 PM
> Subject: policy paper of Siddhi Hirve
> > i o,

> > AT I. TAC MEMBER S,
> > Dear AIL

> > Siddhi has completed the draft of the policy review paper on Abortion.
> > This is attached. Please go through this paper and send in your
> > feedback, comments, suggestions by 25ih September’03, so that we can
> > finalize it and publish the paper. Please also send a copy of your
> > comments to Siddhi Hirve directly . bganatra@vsnl.net OR
>:> sidbela@Asnl.com
> > Best Regards,
> > Ravi Duggal.

> > KINDLY NOTE : We have not enclosed the annexures. In case anybody
> requires the same will forward it immediately.
>>

9/23/03

COMMENTS ON DRAFT POLICY PAPER ON ABORTION

Sudna Tewari
September 19. 2003
oeneral Comments: Congratulations, a very exhaustive and relevant paper

Executive Summary:
Comment: Unsafe abortion as a maternal mortality and morbidity issue would
put the Executive Summary in right perspective.

Pg 3, Para 1: Although its true that the typical abortion seeker who wishes to
limit her family size is over 25 years, there’s a bigger group that uses abortion as
a recourse to spacing. This group is younger and between 20-24 years.
Pg 3, Para 3: The issue of “unmarried women” need not be taken up separately.
In our country, abortion is available to all women. However, a discrepancy needs
to be corrected regarding “ contraceptive failures in married women:

Comment The requirement of 2 doctors forming an opinion for pregnancies upto
12 weeks has been covered by uou subsequently. However, this as an
unnecessary restriction imposed, covered in this section should be useful as its
an important aspect and most difficult to practice in reality.
Pg4, Para3: The fact that the MTP rules lacks a reference to any national or any
international technical guidelines for safe abortion care is not at all a
snortcoming- in fact it is welcome as the Act and Rules in no way govern
technical work, which continuously undergoes advancement and its difficult not
only to modify Act and Rules, but also technical guidelines issued by the GOIthere s a tendency to let old things continue for a long time. In any case, as far as
the Emergency Fluid and Drugs requirement is concerned, it has been linked and
Technical Guidelines are to be issued by the Government.

It must be appreciated that already our Act and Rules are too medicalized, a fact
mentioned by you in your Policy Paper elsewhere.
In view of the above, rny recommendation is that the Protocol/ guidelines should
be totally different, but to be issued in interest of safe abortion.

Pg4, Para 4: Since the Rules were adopted only in June3003 and Regulations
for UT modified at the same time, the other -States are yet to respond on it. They
continue to use the old Regulations

the “ place” as a facility, it would be adequate for him to confirm access to a
registered place, in form of a certificate.

As a comment, its important to mention that this explanation should have been
subjected by Technical Guidelines to be issued by Gol time to time. It’s a new
method- lots will change, including gestation etc etc.
I
I
I

I
I

(

i
i
i
i

!

MTP Regulations

Pg 17,Para 2: The Rules are still very young. The regulations have been revised
only for the Union Territories, which is the responsibility of the Central
Government. As far as I am aware all_the_States are yet to review.
Pg 17, Para1,2,3: Correctly, the problems have been identified. In addition, you
may wish to refer to the Delhi High Court case as detailed in my covering note.

f

I
I
I

I
I
I
I
I
I

Further, its extremely important at this juncture to mention that approval issues
are not to be covered under the Regulations at ail which the states tend to do.
These are covered under Rules and is a central subject and has to be laid before
each house of Parliament. On the other hand powers to make Regulations are of
the states. In section 7 of the MTP Act, the scope has been clearly laid down.

I
I

Medical Abortion

I

I
I
t
I

!
|

t

Pg 20Para 3: There is no restriction to use of medical abortion as per this Act.
The restriction of 7 weeks pertains to the provider at his own chamber as
discussed earlier. The use of the drug is being regulated by the Drug Controller
of India and by the guidelines of MOHFW, Gol.
Pg 2, Para2: Please note that for medical abortion physical standards criteria
has not been specified, unless it’s a part of facilities providing upto 12 weeks
abortion. Also, there is no mention of the transportation issue.

Training
Pg 25, Para 2: The issue of training has been too simplified.

Caseload of 600 as required is absolutely necessary. This gives an average of
60 per month; in lean months it may not be more than 25-30. This includes both
first and second trimester. Therefore in one institution, barely one person can be
trained in one month. One of the biggest problems the government is facing is
the caseload issue. Therefore, the solution is to step up the number of cases for
a training center to be effective and not lower the basic requirement.

Comprehensive Abortion

Pg 26, Para 4: inclusion of HIV voluntary counseling and testing, though
desirable is too idealistic, it would be better to have a referral mechanism for high
risk/ suspected cases.
Pg 27Para 1: Availability of personnel 24 hours, 7 days a week is not practical. A
system needs to be put in place instead.

Commercialization of Abortion

Commercialization in our country is not viewed positively. Its almost akin to “ “
exploitation” or making undue profit.
The heading is very negative and puts all private sector organizations, including
Parivar Seva in a negative light. Better heading should be “ Abortion in the
Private Sector” or something to this effect.
Pg 30. Para 2:

•

The advertisements in Mumbai trains refers to the advertisements of the Pearl
Center. This center contributed significantly to sensitizing the community
regarding legalization of abortion, almost immediately after the MTP Act was
enacted. At that juncture, the community, particularly the woman herself and
her family were not aware that safe and legal abortion could be availed. Also,
the service was provided at a very nominal cost of only Rs 75 for several
years, when the other private sector continued to exploit the women and
charge from her hundreds of rupees.
Parivar Seva through its Mane Stopes clinics followed suit in the north in early
eighties with a price of Ra 100 only. At that time most newspapers on ethical
grounds refused to carry our advertisements informing the masses regarding
legalization of abortion.and its availability. The Ministry of Health and Family
Welfare were reluctant to carry out a media campaign as they felt that the
subject was too sensitive, although an Act had been passed and
consequences of unsafe abortions continued and there was no decrease in
complications from abortion, including maternal mortality.. In fact, I was
personally summoned and managed to convince them of the need.

After a few years, Gol itself launched a media campaign to inform the masses
regarding legalization of abortion, conditions and its availability.

its due to this reason that abortion has become reasonably safe in our
country, although its still notu legal” always. Problems continue and therefore
a wider and continuous IEC campaign is necessary. Also, the cost of abortion

has now come down drastically, both in the private sector as well as public
sector where the cost is supposedly nil.
its interesting to note the last sentence in this para, where you appear to
appreciate the requirement for advertisements—unfortunately, this does not
emerge from your earlier presentation.

®

Please note that it’s the doctors who are not allowed to advertise their
services and not institutions.

•

I am further surprised that you recommend IEC campaign only through
community education. Use of different media for an IEC campaign is a must.
They re-inforce each other. For example, mass media such as
advertisements in electronic media in isolation is not adequate. Similarly, only
education in the community is insufficient. Therefore comprehensive
campaign is required

Para3: “ Enforcement agencies enforced a blanket ban on all advertisements for
abortion services”. There was no clear ban- there was considerable confusion
due to a Proceeding Order of the Court. It was only in few district in Rajasthan
which tried to interpret it differently.
Fortunately, thanks to Cehat, the latest order of 10th September, 2003 that there
is no link with abortion of PNDT. Its crystal clear now.

Pg 30, Para2: The reference “ GOI 200”, is the Workshop in Agra. It should be
“GoLPSS 2000”as this was a Workshop organized by PSS. in collaboration with
Gol. I pas was the other partner. Reference to this Workshop has been made in
the Paper elsewhere, but differently.
Pg 31, Table: There are certain problems. What is the table signifying? The Act,
Rules or the technical practice. Eg:

In no place in the Act or Rules 9 weeks is mentioned. The / weeks is regarding
by provider in a place, which is not registered.
LA or Cervical block is often used with Early abortion.
GA may be required in late abortion.

The word Operation Theater may cause a lot of problems

Pg 32 Para 1: Please add older women, entering menopause, who are come later and are
very desperate.

Para4: ’. he issue of non- allopathic doctors, particularly "ayurvedspius allopaths'" needs to be
covered, who carry out major gyanae operations.

Pg 33. Last Para: The 8 weeks gestation limit is for the PHCs where the infrastructure is
very minimum and a new technique is being introduced. It’s a pilot to try a new thing and is to

be scaled up. In any case, this was prior to the amendment to the Rules.

Pg 34, Parai: Please make a reference to Parivar Seva paper submitted at Agra
conference.as Kaipagam ( 2000) and the reference couid give details as in case of Sheriar.
Our experience of several years with thousand of cases needs to be quoted.

Para 2: There is

a paper on charging of informal fees in Orissa, which has been

documented.The paper is by Banerjee . 2001 and was presented in the State meeting in
October 2001 The reference is

“ Rapid Assessment of Abortion Clients- a Qualitative Case Study in selected districts of

Orissa, presented by Dr Aiok Banerjee at the ’ Orissa State Level Workshop on Making

Abortion Safe and Accessible", held in Bhubaneshwar 15-17 October, 2001, by Parivar Seva
Sanstha in collaboaration with Government of Orissa. If you wish, we could send you a copy.

Acknowledgements

Pg 37: Please spell my name as “Tewari” and not Tiwari. Thanks

References

My earlier comments stand.
Under Sheriar: in details given, please include Parivar Seva and Ipas

Opinion

V-A '■

cause the Queen Mother never did
change, staying faithful to her hats and
pastel dresses, her horse-racing friends
and her sweet-faced rejection of the
slightest intrusion into her privacy, she
still had millions of mostly elderly admir­
ers when she died. As the last such royal,
she now leaves the monarchy exposed. As
long as she lived, there was at least one
firewall against an all-out critique. Some­
how it seemed indecent to attack too
fiercely an institution of which this un­
naturally durable relic of the Edwardian
age remained the oldest representative.
All is not lost. Her daughter, Queen
Elizabeth II, has retained much of her
mother’s untouchable dignity. She is dutih fill to a fault, an impeccable performer of
* her public role, and beyond the criticism
\ that so many of her own offspring attract,
i But even she has become a defensive fig| ure, known to be worried about her public
image, desperately in thrall to courtiers
doubling as image consultants, a trade her
mother would barely have been aware of.
Her son and heir, Prince Charles, publicly
agonizes over just about every aspect of his
life with a candor that owes much to Sig­
mund Freud, rather less to the dignity that
has hitherto marked his rank. And the rest
of the royals—princes and princesses, di­
vorces and other troubled hangers-on—
continue to attract ever-increasing con­
tempt from a public more voracious for
royal scandal than for the respectful si­
-■4 fl
lence that enshrouded most of the Queen
t ■
Mother’s life.
She leaves a country that talks more
than it has ever done about the advan­
tages of exchanging the monarchy for a
republic. This, in my opinion, will not happen for decades, or
even perhaps in this century. It is a waste of political time even
to discuss it. Though the British have lost their respect, they
have not ceased to be among the most conservative people on
earth. A referendum on the monarchy would produce, in an age
when elected politicians are more unpopular than ever, a strong
endorsement. Where would our tourist industry be, without the
changing of the monarch’s guard? What would the papers have
to write about, if princesses had been sent to the virtual guillo­
tine? Would we prefer to elect some inoffensive nonentity as
president, instead of taking our chances with nonentities of the
blood royal? These are the arguments that would win the day.
The Queen Mother, in her way, was not a nonentity. She re­
tained a certain aura by declining to observe the rules of the
modern age. She became, by her very longevity, an extraordi­
nary person, further out of reach of real life than she had been
when she was pitched into queendom. We came to look at her
as a kind of freak, not just for her years but for her connection
to a world that has totally disappeared. Now that she has gone,
the monarchy faces, rather bleakly, a world it can never again
be sure of.

Farewell to .an
Icon and .an era

Britain’s venerable Queen Mother was the last
^pbodiment of the monarchy of old
By Hugo Young
ritain’s Queen
Mother was a
piece of the an­
cient past, and she
reveled in the role.
She predated the modern
monarchy, and was allowed
to remain locked in a differ­
ent era. That was the whole
point of her: to remind the
people that an institution
they no longer revere had,
once upon a time, enjoyed
respect bordering on wor* ship. She was the last em­
bodiment anyone will ever
v see of royalty as it used to be:
I
and, remote, demanding
M contemptuous of any­
-i'-l "h
thing that might be called ac­
countability to the public­
least of all to the media, the
enemy that dogs the foot­
steps of all her heirs and successors.
It is a bit of a myth to say that she was loved. She became an
icon to whom it was customary to apply that term, but the affec­
tion was a ritual. She was known, without rancor, for her little
foibles: her amazing extravagance, her reactionary attitudes, her
fondness for a tipple. In any other member of the royal family,
these traits would have been critically deconstructed. But the
Queen Mum was sanctified as a national treasure. She grew so old
that the preparations for her death became indecently explicit: the
BBC’s fabled rehearsals for the great moment, the black ties in
every news anchor’s desk drawer, the obituary sound bites that
politicians kept on the databases. In that sense, too, she tran­
scended common humanity.
For the older generation of Brits, she was a reassuring figure.
They, like her, could remember the days when royalty retained
an unchallenged place in British life. They remembered the cir­
cumstances in which the job of queen was thrust upon her,
when her brother-in-law, Edward VIII, abdicated to his own
self-indulgence. They witnessed her performance during World
War II, when she bravely offered comfort to the victims of
Hitler’s bombs. This was still the period when such gestures
took on an otherworldly quality, with the monarch and his con­
sort descending from on high to move among their people. Be■

/

■

NEWSWEEK

APRIL 8/APRIL 15, 2002

y

f 'll

YOUNG is a columnistfor the newspaper The Guardian.

23

Asia

•I
li
11

IN THE OPEN: Since
some abortions are
legal, doctors have all
the tools to perform
the procedure at hand

The clash between greater sexual openness and continued conservative attitudes
has had a surprising side effect—a boom in abortions. By GREGORY BEALS

Korea’s Dark Secret
HEY

FIRST

MET

AT

THE

Christian Club when she was at
university in Seoul. He was an
architecture major, 26 years old
like her, tall, clean-cut. They be­
gan dating, and after a year they
had sex. She enjoyed it partly for
ffie physical pleasure, but mosdy because of
the deep devotion she felt for him. They
had mapped their future together—mar­
riage, a family—all the things young Kore­
ans are meant to desire.
A few months later, she missed her pe-

24

riod. The next diing she knew, she was in a
doctor’s office, having an abortion. When
the 10-minute procedure ended, she was
wracked by anxiety. The man who promised
her his heart abandoned her because of the
abortion. She never told her family for fear
that her shame would become theirs. She
worried that university counselors would
eject her from school if they knew of the
procedure. Girlfriends would have dis­
owned her. Three years later, she’s married
to another man and pregnant vdth a child
she longs to have. But the secret of the abor-

tion lingers inside. “1 can’t tell my husband,”
she says (she asked Newsweek to with­
hold her identity). “If he knew the truth he’d
probably divorce me.”
Even in the West, having an abortion is a
traumatic experience. Korean women not
only have to deal with a far greater degree of
cultural stigma, but the procedure is techni­
cally illegal. (Abortions are allowed only in
cases of rape, disfigurement of the child or
threat to the mother’s health.) Yet govern­
ment officials estimate that between 1.5 mil­
lion and 2 million abortions are performed
NEWSWEEK

APRIL 8/ APRIL 15, 2002

1

in South Korea each year—roughly the same ers. Until the mid-1990s, it was not uncom­
number as in the United States, a country mon for a couple walking the streets of
with six times the female population. For Seoul to be berated for holding hands in
every child born in Korea, roughly three are public. Now Korean culture at large has be­
aborted—one of the highest rates in the come much more open about sex. One of
world. The numbers are shocking testimony the top box-office draws at Korean theaters
to the unsetdcd sexual landscape in Korea, last year was “Yellow Hair,” a tale ofthe sex­
where mores are shifting too quickly for die ual adventures of two women and a man.
system to catch up. “We are seeing a clash of “Downfall,” the story of a Korean prosti­
values in Korean society,” says Han Sang- tute, was shown to packed theaters in 1997.
soon, director ofAeranwon, a shelter for un­ The Internet explosion—in a country with
wed mothers. “Abortion is the result.”
one ofthe highest rates of broadband usage
Before the 1950s, conservative
dal attitudes led to few aboruons being performed in the
Confucian country. But in the
1960s, as citizens were urged to
have fewer children in the name
of national development, the
procedure became accepted as a
means of family planning. Most
patients were married women
who did not want to have more
children; between 1966 and
1973, the birthrate fell from 35.6
to 28.8 kids per 1,000 people.
Then in 1973, just as Roe v. Wade
legalized a woman’s right to
choose in die United States, a
conservative backlash in Korea
led the government to ban the
\
• procedure. The clock, however,
could not be turned back. Thouj sands of doctors continued to
'rform abortions openly in
aics, causing the birthrate to
decline even further, to 15.6 per
1,000 in 1990.
Flouting the law is remarkably
easy. Since some abortions are
legal, gynecologists must be
trained and have all the neces­
sary equipment to perform the
procedure. The government, g
embarrassed by the high number i
of Korean children put up for |
adoption overseas, is thought to |
be reluctant to crack down. Doc­
tors, who make between $80 and
$300 per first-trimester abor­
tion, similarly have incentives to fudge mat­ in the world—has opened a whole new
ters. If questioned, tiiey can argue tiiat hav­ world of sexual imagery to Korean youth.
ing die child would impair the mother’s Kids playing wildly popular online strategy
“mental health.” For young women, asking games are inundated with pornography ad­
for an abortion is as easy as walking into a vertisements. “When it comes to sex,” says
doctor’s office. The high rate of abortions, Aeranwon’s Han, “the children are running
says an official at the Planned Parenthood and the parents are crawling.”
Federation of Korea, “is our greatest shame.”
Yet what Korea’s unusually high abortion
The trend is fueled by loosening sexual rate may really be demonstrating is the per­
mores. Nowadays, instead of married sistence of conservative attitudes. A great
women who cannot afford another child, many unwanted pregnancies can be attrib­
most patients are young women who want uted to a lack of education about safe sex.
to avoid the shame of being unwed modi- Many Korean parents don’t discuss the sub­

■

NEWSWEEK

APRIL 8/APRIL 15, 2002

ject with their daughters, assuming that
they will remain virgins until marriage.
While die government has developed a
high-school sex-education program diat is
more modern in scope, many conservative
administrators simply refuse to teach the
material. “Usually die schools only teach
the difference between men and women
and give a basic idea of biological struc­
tures,” says Kim Soung-yee, a professor of
social work at Ewha University in Seoul.
Two years ago, the government’s censor
board banned an MTV show
promoting AIDS awareness be­
cause it mentioned the word
“condom” too frequentiy; a con­
dom manufacturer was pre­
vented from airing its ads at the
same time. The Roman
Catholic Church, a powerful
lobby in Korea, insists that such
actions make sense. Mention­
ing contraception “will just en­
courage more free sex,” says die
Rev. Paul Lee of Korea’s
Catholic Bishops’ Conference.
Once pregnant, women face
an uncomfortable reality: The
stigma of unwed motherhood is
greater dian that of having an
abortion. Students are often
forced to drop out of school.
Working women can find their
careers jeopardized. “There’s a
kind of environmental pres­
sure,” says Ewha University’s
Kim. “They think if they got
pregnant they are shamed, so
they leave the office.” Abor­
tions, too, are not openly ac­
knowledged. But die procedure
at least allows society to wash
its hands of the problem of un­
wanted pregnancies. That
helps explain why despite vehe­
ment opposition from both the
church and the Korean Medical
Association, the government
recendy approved Norlevo, the
“morning-after” pill, in Korea.
Nodiing will solve the larger problem,
however, except greater education—some­
thing that remains depressingly far off. One
gynecologist with more than 10 years of ex­
perience performing dozens of illegal abor­
tions told Newsweek: “Every time I do it,
I have doubts. The first tiling I think about
is my children.” Yet when asked how she
teaches her teenagers about sex, the doctor
says, “I always want to talk, but it’s very dif­
ficult for me. We feel embarrassed about it.”
Until that stigma is removed, no magic pill
will erase Korea’s shame.
■

25

The Paramilitary
ALVATORE

MANCUSO

IS

A

wanted man. The 37-year-old
military chief of Colombia’s
outlawed right-wing militias
was convicted in absentia last
month of organizing armed
“vigilante groups” and sen­
tenced to 11 years in prison on charges
arising from the November 1997 murder
of a small-town mayor. But in the humid
lowlands of northwestern Colombia,
where the country’s ruthless paramilitary
forces reign supreme, Mancuso is an un­
touchable warlord whom no one dares
cross. That crude fact of life seems to ap­
ply to the government of lame-duck Presi­
dent Andres Pastrana as well—despite two
outstanding warrants for his arrest. “We
have replaced the state in various areas,”
Mancuso told Newsweek in an exclusive
interview at a paramilitary camp two
weeks ago. “We have had to arm and de’ fend ourselves, we build schools and
health clinics—all because the state has
failed to fulfill its constitutional duties.”
Mancuso and his estimated 8,000 com-

26

rades in arms have indeed become a state
within a state in vast tracts of the Colombian
countryside. The U.S. Drug Enforcement
Agency says the militias fund their opera­
tions with cocaine-smuggling profits, an al­
legation Mancuso now disputes. No one de­
nies that the self-styled United Self-Defense
Forces of Colombia (AUC) have acquired a
military capability in recent years that puts
them on a par with the country’s more nu­
merous and longer established communist
guerrilla armies. As Colombians from nearly
all walks of life swing sharply to the right in
outrage over the summary executions and
kidnapping practices of the nominally
Marxist Revolutionary Armed Forces of
Colombia (FARC), the six right-wing mili­
tias grouped under the AUC’s umbrella
banner have never wielded more power at
home. “They have grown at such a rapid
rate that they are now fast approaching the
FARC,” says counterinsurgency expert
Thomas Marks of the Hawaii-based Acade­
my of the Pacific. “The FARC has adopted
the paramilitaries as their main enemy in­
stead of the Colombian armed forces.”

There is mounting evidence that the
right-wing militias’ power is no longer con­
fined exclusively to the battlefield. Colom­
bia held congressional elections in mid­
March against the backdrop of hard-line
presidential candidate Alvaro Uribe Velez’s
meteoric rise in opinion polls. Dozens of
pro-Uribe candidates won seats in both
houses of the national legislature, and Man­
cuso issued an ofiicial communique hailing
the results that, by his reckoning, delivered
victory to more than one third of the para­
military forces’ preferred candidates.
Some of those congressmen-elect were
political unknowns prior to the voting, and
left-of-center politicians accused AUG lead­
ers of restricting their freedom to campaign
in areas under the militias’ control. Interior
Minister Armando Estrada expressed
“grave” concern over the alleged infiltration
of the National Congress by known paramilitary elements and their supporters. “If
we don’t confront the paramilitary forces
head on, they will increasingly become the
biggest threat facing the country,” says Luis
Alberto Moreno, Colombia’s ambassador to
NEWSWEEK

APRIL 8/APRIL 15, 2002

PNDT SURVEY

A. PROFILE OF ULTRASONOGRAPHY CENTRES
Sr. No./
specify if
Indiv
provider
or Hosp
I

Name, Qualification
and Address of Owner

3

2

qX«.™s(C<,12-4):

Private ; Is Owner ! Qualifi
, Non­ and actual cation
of user
user of
profit
Public m/c same of m/c
4

5

Usme ! No. of USG done for
7
previous
m/c
Month
Day
Week
Since
when
Pg oth pg oth pg oth
7
6
T

Whether USG m/c
registered, if Yes, Reg
No. and approx date of
registration.

8

l.MD.OMO/DGO; 2 MD (Radiology): 3 Diploma in Radiology; 4. MD/MS (olhei). S MBBS;

6 nonallopathic degrees (BAMS/BHMS/BUMS etc.) 7 Othertmnmedical

- OU. <0lhe. like kidney, cardiac etc) ultrasound.

?ol ? I
B. Name of.be I.ealUy/ <«»" /

from wind, me mforma.mn is e.UeeUd and wha, is .he popoM." base?

(a) Locality/Town/Area Name:
(b) Population as per 2001 census of this area:
Information Collected by
Remarks, if any:

How to do the Study
The Objective of this rapid survey is to generate alternate information to whal the state
governments are doing. The experience with the Supreme Court case shows that the
states are doing a very inadequate job of both identifying and registering the USG
centers. Hence to provide information support in order to strengthen the SC case, this
rapid sample survey will help in providing a basis which can be used to show the court
and the governments the deficiencies in the process of survey and registration. The
format provided is the minimum that should be done. If you feel there is additional
information you would like to collect then you may do that but do remember this is a
rapid survey and having too many additional questions will increase the time factor.

This rapid survey will be multi-centric to be done in as many towns and cities as possible
and feasible in the next one month. The methodology is described below.

Since specialists are located mostly in urban areas - towns and cities, the focus would be
to do the study in urban areas. In urban areas the expected number of gynnect louists
would be between 15-30 per lakh population and radiologists 5-15 per lakh, witli higher
concentrations in the larger cities.

What would be the source of information to do the listing? At the district level and in
most towns the two main sources of information are pharmacy stores and medical
representatives associations. The latter and/or some commercial body may even have
published directories of all medical practitioners and establishments. Other sources
include the local Indian Medical Association, Ob&Gy Association, Radiologist
Association etc.. The district health and medical officer may also have some list.
How would the sampling be done? In small towns upto 300,000 population the entire
town could be covered. In larger cities 3-5 localities or municipal wards could be covered
(keeping in mind the time frame and deadline we cover as much as we can). Where
selection is involved then select the localities/wards randomly and complete a defined
area (an area for which the population of 2001 census is known). This is important
because on the basis of the listing we should be in a position to estimate the number of
USGs in the state/country per population unit.

Through this exercise you may generate a list of all practitioners and hospitals in your
area through directories or lists supplied by various people. This initself will be a useful
database and you must keep that and send one copy, if necessary buy it, to the central
study team. In the format fill out only the details for the Ultrasound centers. 1 his will
have to be done by visiting the Ultrasound centers identified through the listing. The
information in the format is simple and should not be difficult to collect. If there are any
refusals then collect the information from neighbours, patients, closeby pharmacy store
etc.. (This will not involve ethical violation because we are doing it in the context of
unethical practices by those owning ultrasound machines.)

SUMMARY OF STEPS
1. Decide on the central research team who will receive the filled up formats and
compile and analyse the information
2. Understand the Format and methodology of data collection
3. Identify where you want to do the study
4 Select the sample area, where needed
5. Using various sources of information discussed above to generate the list of
ultrasonography centers.
6. Physically visit the centers and fill up the format

Other Information

Format printing costs and data analysis costs for the survey in Maharshtra con Id be borne
by CEHAT, in the other states there can be collaborations.
The format and methodology must be explained .

I

Vxj fA ~

J

THE NEED FOR ACTION AGAINST FEMALE FOETICIDE IN INDIA
{ By Dr. Sabu George }

RECOGNIZING VIOLENCE AGAINST WOMEN
Violence against women exists in various forms, in all societies, the world over.
However, the recognition that elimination of gender based violence is central to equality,
development and peace, is recent. In India the landmark report on the ‘Status of Women1975’ did not deal with this issue. Then in the late seventies and eighties, the Indian
women’s movement focused on issues of dowry deaths, female foeticide, sati, rape and
other forms of violence. More recently, international conferences, such as the Vienna1993, Cairo-1994, Copenhagen-1995 and Beijing-1995 explicitly highlighted this
problem. The World Health Assembly in 1996 endorsed the fact that violence against
women is a public health problem. In 1998, the 50th anniversary of the ‘Declaration of
human rights’ was celebrated by the UN with a global campaign for elimination of
gender based violence, lire objective was to influence public opinion and attitudes,
policies, practices and legislation to facilitate a violence free life for women.
Female foeticide is one extreme manifestation of violence against women. Female
fetuses are selectively aborted after prenatal sex determination, thus avoiding the birth of
girls. In India where female infanticide has existed for centuries, now female foeticide
has joined the fray and is increasing each day. The reasons for this evil are the
introduction and proliferation of prenatal diagnostic test / sex determination clinics and
cheaper ultrasound machines that help determine the sex of a child before it is bom.
Dramatic reduction of birth rates in most of India’s states has contributed to
intensification of son preference in the existing patriarchal society. One must also not
forget the lack of ethics in pockets of the medical profession that result in furthering
female foeticide. For instance, in Tamilnadu the establishment of numerous ultrasound
clinics in semi-urban areas, since the mid-nineties, is not a widely known fact; that even
rural families in the state have begun to commit female foeticide to satisfy their
preference for sons. In Haryana residents of upper caste hamlets openly admit to the
widespread practice of female foeticide. Parents tend to be calculative in choosing the sex
of the next child and the decision is based on the birth order, sex sequence* of previous
children and number of sons. Transfer of reproductive technology to India is resulting in
reinforcement of patriarchal values, as professional medical organizations seem to be
indifferent to ethical misconduct. These facts have to be publicized so that awareness can
be raised and appropriate action by the state and civil society is initiated.

THE FAILURE OF ACTIVISTS, NGOs AND THE MEDICAL PROFESSION

Most NGOs and the medical profession concerned with female foeticide, for the
past two decades, failed to recognize the likelihood of its rapid spread. The first private
clinic was set up in Amritsar in 1979. This trend soon spread to other cities in North and
Western India, resulting in adversely influencing the sex ratio in those parts of the
country. A ten year gap ensued before the proliferation of these clinics began in Southern
India. In the early eighties attention was being given to the issue of female infanticide but

I

the activists had not anticipated the problem of female foeticide. Although the spread of
this problem was initially slower, many taluks even in backward parts of Karnataka and
Andhra Pradesh now have sex determination clinics. There were occasional media reports
from 1992 onwards about the abuse of ultrasound for fetal sex determination in major
cities of Tamilnadu. Despite expression of concerns, from the mid nineties, about the
prevalence of female foeticide in rural areas, NGOs and others involved in work against
infanticide did not prioritize action against foeticide. Even elementary steps were not
taken; for instance there was no lobbying with the state to set up the mechanisms to
register sex determination clinics, as mandated by the 1994 national law; and there also
was a failure to confront the medical profession’s insensitivity to the gross violation of
medical ethics.

INTENSIFICATION OF SON PREFERENCE RELATED TO FERTILITY
DECLINE
Fertility decline has taken place in all economic and social groups in most parts of
the country, especially in Tamilnadu. The sharp fall in birth rates from the eighties is one
contributory factor for intensification of son preference. Similar developments have been
earlier observed in other patriarchal societies such as China, South Korea, Taiwan etc.,
with the decline in fertility rates. Sex determination methods were being used from 1979
onwards in North India to manipulate sex composition of children to have greater
proportion of sons. In 10 years, the sex ratio of pre-school children in Punjab dropped
from the already low levels [ 925 to 874 during 1981-1991]. Sharp declines also
occurred in Haryana and Rajasthan, states where female foeticide is widespread . In less
than a year the 2001 census will reveal the present situation in Punjab and other states.
The indication we have from the grassroots level is that there will undoubtedly be an
even steeper fall against girls. There are more than one thousand ultrasound clinics in
Punjab and elaborate networks from the village level to the nearest urban ultrasound
clinics for referrals exist, where each link gets a commission from the clinics.

In Tamilnadu, the hospital birth data in recent years, reveals an increased
masculination in sex ratio at birth [109 boys per 100 boys as opposed to the expected
105]. This is essentially an urban sample. The 2001 census may not see any significant
improvement in the sex ratio of surviving children in Tamilnadu. However, we will have
no definitive information on whether there is a decline in infanticide due to replacement
by female foeticide. But one thing is quite certain, the establishment of sex determination
clinics is the early warning sign for the impending drop in sex ratios. It takes a decade for
the practice to spread and gain widespread social acceptability; and, if a significant
number of families in the new millennia start opting for one or more sons with none or
fewer daughters, there will be an alarming drop in sex ratios. Our challenge is to reduce
the anti-girl attitude of our society before fertility becomes less than two [given current
fertility levels, women will have an average of nearly 2 children during the child bearing
years].

THE SIGNIFICANCE
TECHNIQUES

OF

THE

LAW

ON

PRENATAL

DIAGNOSTIC

Recent history of social legislation in India is hardly encouraging as far as
implementation is concerned. However, the national law against prenatal diagnostics is a
positive step. For fifteen years (1979-1994), when private sex determination clinics were
first established and the practice of female foeticide flourished in north-western India, the
people had received no message questioning the morality of this practice. The enactment
of the law enabled the National Human Rights Commission to direct the Medical Council
of India to take action against doctors found abusing prenatal diagnostic techniques.
Today, blatant advertisements for fetal sex determination once seen in Bombay trains in
the early eighties and in Delhi newspapers in the late eighties and nineties have virtually
disappeared. Thanks to these laws.

The first state law enacted in Maharashtra against sex determination was the
Maharashtra Regulation of Use of Prenatal Diagnostic Techniques Act, 1988. This was
the result of vigorous public campaigning in the state. After this law was effected, the
number of Sex Determination (SD) clinics in Mumbai went down and the practice of SD
also lessened. This achievement was all due to sustained campaigning and active
monitoring of the Act by the FASDSP [ Forum against Sex Determination and Sex Pre­
selection]. Unfortunately this campaign faltered when the FASDSP became non
functional and quite a few of the Mumbai sex determination clinics resumed operation.
However this campaign proved that a lot can be accomplished by sustained efforts and
eradicating complacency in the state governments. All future campaigns have to learn
from the shortcomings of the abortive Maharshtra campaign. State Governments should
realize the importance and priority of the present law and not merely treat it with their
usual complacency. Tamilnadu is one such state that has yet to take effective and
prompt action in the implementation of this Act.

t

k

The inadequacies of the present law are largely because the Government of India
has not been seriously committed to achieving the intent of this Act - the elimination of
Sex Determination Testing. Also, due to effective lobbying of doctors, in the early
nineties, several positive features of the Maharashtra Act 1988 were watered down in the
1994 National Act. A recent administrative directive from the Family Welfare Ministry
excluded a sex determination technique like Erikson’s from the purview of the 1994 Act,
asserting that it applied only to tests conducted on pregnant women. The immediate
reaction to this directive was the resumption of newspaper advertisements in North west
India again promoting this sophisticated reproductive technology.
These very
Advertisements had been stopped only a year before when a petition challenging the
illegality of these advertisements was filed with the Punjab Human Rights Commission
by 6 Women Against Violence’. The unwillingness of the Government to interpret the
legislation to keep it in tune with the inexorable progress in technology is self defeating.

■

MEASURES REQUIRED TO REDUCE FEMALE FOETICIDE

Structures for implementation of the 1994 law need to be created at district
level. Volunteers have to be actively mobilized to monitor registration and functioning
of sex-determination clinics, in different districts. Effective alliances with ethical doctors
have to be made from the local levels. Test cases have to be filed against the violators;
also important is that we persevere with the media to highlight obstacles in
implementation of the Act. Social consciousness has to be raised against this crime.
Simultaneously we have to get involved in actions to ensure that the public at large
becomes supportive of this campaign. Lobbying with political parties to put this issue on
their agenda is imperative. All this is just one step towards efforts to empower women in
our society.
Deteriorating women’s status and the emergence of female foeticide is not a
unique sociological phenomenon confined to a particular state, but a countrywide trend
even in diverse cultural contexts where there has been relative greater gender equality,
such as the Uttarkhand hills or the Kashmir valley. Our challenge today is to initiate a
vibrant, effective campaign against female foeticide. Jammu & Kashmir is important as it
is the only state in the country where there is no legal prohibition against sex
determination testing. Earlier campaigns in the country against sex selective abortions
failed, despite the moral correctness of the issue, as they could not create a sustained
social movement against this crime. To stem the increasing epidemic of female foeticide
we have to expose the collusion of unethical medical practitioners with the patriarchal
society. The campaign has to oppose the commodification of women in popular culture
and media. Organizations and individuals with different priorities and ideological beliefs
have to rally together to battle powerful patriarchal forces operating within institutions of
the family, government and civil society. A transformation of our gendered society, is

necessary for the elimination of female foeticide.

Acknowledgements:
An earlier version was presented to the Chennai Consultation on Female Foeticide,
December 1998. organized by SIRD Madurai. Sabu was supported in part by UNICEF.

3,^

I
woH ~ "S'

The Need for a Campaign in TamilNadu against female feticide
Dr. Sabu George

Introduction

Violence against women exists in various forms in all societies. Flowever, the recognition
that elimination of gender based violence is central to equality, development and peace is recent.
In India, the landmark report on the Status of Women-1975, did not deal with this issue. The

Indian women’s movement in the late seventies and eighties organised around the issues of

dowry deaths, female feticide, sati, rape and other forms of violence. Recent international
conferences such as the Vienna-1993, Cairo-1994, Copenhagen-1995 & Beijing-1995 have all
explicitly highlighted this problem. The World Health Assembly in 1996 endorsed that violence

against women is a public health problem.

United Nations agencies celebrated the 50,h

anniversary of the Declaration of human rights, in 1998, with a global campaign for the
elimination of gender based violence. The objective was to influence public opinion and

attitudes, policies, practices and legislation to facilitate a life free of violence for women.

The ‘Platform for Action’ of the Fourth World Conference on Women stated that there
exists worldwide evidence that discrimination and violence against girls begin at the earliest
stages of life and continue unabated throughout their lives. Our focus is on female feticide which

is one extreme manifestation of violence against women. Female fetuses are selectively aborted

after prenatal sex determination, thus avoiding even the birth of girls. The establishment of large

number of ultrasound clinics in semi urban areas all over in TamilNadu since mid nineties is not
widely known. That even rural families in the state have started committing female feticide to

satisfy their preference for sons has to be publicised so that awareness can be raised and

appropriate actions by the state and civil society be initiated. Otherwise, the incidence of female
feticide will continue to increase and the under five child sex ratio will further worsen against

girls over the next decade. Whereas, the practice of female infanticide in TamilNadu received
widespread acceptance at various levels by the mid nineties, the epidemic of female feticide has

still not been acknowledged, let alone viewed as a flagrant violation of human rights by the state.

Regrettably, even certain segments of donors are unaware of the existence of the 1994 Prenatal
diagnostic law.

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The lack of ethics in the medical profession, coupled with technological advancement­
rtf .
reliable and cheaper ultrasound machines in the ninetiesfenabled fetal sex testing accessible to
'S

a much larger population. Dramatic reduction of birth rates in the state since the eighties
contributed to intensification of son preference in our patriarchal society. Undoubtedly, the

2

indifference of the Government of TamilNadu in implementing the 1994 national legislation
forbidding prenatal sex selection as late as December 1998, facilitated the popularisation of
female feticide to the entire rural population. Further, those who practiced female infanticide in

rural areas legitimised their actions by arguing that if female feticide is permissible then

infanticide should also be accepted by the state. It is this pathetic situation which calls for the
launch of an effective campaign to eliminate female feticide.
Anti-women developments in TamilNadu
There were progressive social reform movements in TamilNadu in the early part of the
century. Women’s literacy and employment in the formal sector increased over the last 50 years.

These favourable factors hardly contributed to the empowerment of women as the patriarchal

controls on majority of women have not changed substantially. About 5 decades ago, dowry was

absent among most castes. However, during last half a century dowry became a common practice
among all classes and castes. In fact, in several castes such as Kallars the traditional practice was

bride price. The proportion of consanguineous marriages have dropped over the last few
decades. There is the growing preference for hypergamous marriages motivated by desire for

social mobility. Anthropological studies have confirmed that usanskritisation' among the
intermediate and lower castes following economic prosperity has led to devaluation of women.
Changes in cropping patterns and agricultural practices have also been held responsible for the
marginalisation of rural women. The practice of female infanticide increased from sixties, so
much so that there has been a pronounced deterioration of preschool child sex ratios (995 to 948

girls per thousand boys over the 1961-91 inter-censal period). Infanticide of newborn girls has

marred the positive development of the decline in infant and child mortalities in TamilNadu over
the last 3 decades. Given this background of increasing anti-women practices, the acceptance

of fetal sex determination testing from the nineties should not have been a surprise.

The failure of activists
Firstly, some of us who have been concerned with female infanticide for the last one and
a half to two decades failed to recognise early, the likelihood of the emergence of feticide in rural

TamilNadu. A ten year lag in the spread of SD clinics from Northern and Western India to
***

Southern India made us complacent to the possibility that female feticide could arise or substitute

infanticide. There were occasional media reports from 1992 onwards about the abuse of

7

3

ultrasound for fetal sex determination in major cities of TamilNadu. Despite expression of
concerns from the mid-nineties about the prevalence of female feticide in rural areas NGOs and
others involved in work against infanticide did not prioritise action against feticide. For instance,

even elementary steps were not taken; like-

1.

Did not lobby with the state to set up the mechanisms to register sex determination clinics
as mandated by the 1994 national law.

2.

Failed to confront the medical profession’s insensitivity to gross violation of medical

ethics.

Intensification of son preference related to fertility decline
Fertility decline has taken place in all economic and social groups in TamilNadu. The
sharp fall in birth rates from the eighties is one contributory factor for intensification of son

preference. Similar development have been earlier observed in other patriarchal societies such
as China, South Korea, Taiwan etc., with the decline in fertility rates. Because, the preference

for sons decreases at a slower rate then the total number of wanted children. The first private sex
determination clinic in India was established in Amritsar in 1979 and soon spread to other parts

of Punjab and Haryana. Not surprisingly sex determination methods were being used from 1979

onwards in North West India to manipulate sex composition of children to have greater
proportion of sons. In 10 years, the sex ratio of preschool children in Punjab dropped from the
already low levels (925 to 874 during 1981 to 1991). Sharp declines also occurred in Haryana

and Rajasthan, states where female feticide is widespread. In less than six-tnoftths, the 2001
Census will reveal the present situation in Punjab^ The indication we have from the grassroots
is that there will undoubtedly be a even steeper fall against girls. There are more than one

thousand ultrasound clinics in the state! And elaborate networks from the village level to the
nearest urban ultrasound clinics for referrals exist; where each link gets a commission from the

clinics. Demographers have also predicted a declining trend in child sex ratio for Punjab in the

next census.
In TamilNadu. the hospital birth data of the recent years has revealed an increased

masculmation in sex ratio at birth (109 boys per 100 boys, as opposed to the expectation of 105).

This is essentially an urban sample. The 2001 Census may not see any significant improvement
in sex ratio of surviving children in TamilNadu.

However, we will have no definitive

4
information on whether there is a decline in infanticide due to replacement by female feticide.
It is possible that the rural incidence of feticide over the last five years may be small and
therefore the impact on sex ratios may be imperceptible in several regions of TamilNadu in the

forthcoming Census. However, the lessons learnt from other countries and Punjab should not
be forgotten for TamilNadu. The establishment of sex determination clinics is the early warning

for the impending drop in sex ratios. It takes about a decade for the practice to spread and gain

widespread social acceptability. We should keep in mind that the fertility rate in TamilNadu is
predicted to be approximately 1.5 children by 2005. Therefore, there will be an alarming drop

in sex ratios if a significant number of families in the new millennia start opting for one or more

sons with none or fewer daughters. Our challenge is to reduce the anti-girl attitude of our society
before the fertility becomes less then two (given current fertility levels, women will have an
average of nearly 2 children during the child bearing years).

The significance of the law on prenatal diagnostic techniques
[Recent history of social legislations in India is hardly encouraging as far as their

implementation is concerned, j ButIwe are of the firm viewfhat the national law against prenatal
diagnostic is a positive step. The state has an obligation to take the right moral stand. Note that
for 15 years (1979-94). when the private sex determination clinics were first established and the

practice of female feticide flourished in North Western India; people had received no message
questioning the morality of such violence against women. The enactment of the law enabled the

National Human Rights Commission to direct the Medical Council of India (MCI) to take action
against the Doctors for abuse of sex determination. Regrettably, it took three years for the MCI

to respond. The blatant advertisements for fetal sex determination seen in the Bombay trains in
the early eighties and in the Delhi newspapers in the late eighties and early nineties have virtually
disappeared thanks to laws.
Critiques of the failure of social legislations have pointed out that one major reason for

non-implementation is that the pressure groups who were behind the framing of the law have

often not actively lobbied for the implementation. Often, the very enactment itself gave a false
sense of achievement resulting in complacency. The vigorous public campaign in Maharastra
led to the first state law against sex determination- Maharastra Regulation of use of Prenatal

Diagnostic Techniques Act, 1988. In fact, the number of SD clinics in Bombay went down and
the practice of sex determination lessened. The sustained campaign and the active monitoring

5

of the Act by the Forum against Sex Determination and Sex Pre-selection (FASDSP) was
responsible for this achievement. This evidence needs to be kept in mind. Therefore the

argument of the law school students that the state cannot realistically regulate private ultrasound

units to prevent sex determination is not tenable. Most of the Bombay sex determination clinics
resumed practicing only after the historic campaign faltered, when the FASDSP became non­

functional. Our proposed campaign in TamilNadu has to learn from the shortcomings of the

abortive Maharastra campaign.

The callousness of the TamilNadu Govt, in implementing the Act needs to be emphasised.

The state Govt, promptly gazetted the Rules for the implementation of the Act in February 1996
immediately after the Government of India did. However, nothing else was done. The Health
Secretary informed in November 1998 that the Advisory Board constituted under the Act had

never met. Not a single clinic has been registered even three and a half years after the rules were
framed. The Appropriate Authority informed that he did not have funds to advertise that

ultrasound clinics have to be registered. The very fact that the TamilNadu Appropriate Authority

chose not to attend this Consultation itself is an indication of the priority o f the state Government.

The inadequacies of the present law are largely because the Government of India has not
been seriously committed to achieving the intent of the Act- elimination of sex determination

testing. Several positive features of the Maharastra Act, 1988 have been watered down in the
1994 National act thanks to the lobbying of Doctors in early nineties.

For instance, the

appointment of a busy Government official with multiple responsibilities as the sole Appropriate

Authority was to make the Act ineffectual. Just to get an appointment with the State or Central

Appropriate authorities can take several months. The frivolousness of the Central Government
is evident from a recent administrative directive from the Family Welfare Ministry which

excluded a sex determination technique like Erikson’s (sex preselection) from the purview of the

1994 Act asserting that it applied only to tests conducted on pregnant women. The unwillingness
of the Government to interpret the legislation to keep it in tune with the inexorable progress in
technology is self defeating. The immediate reaction to this directive was the resumption of

advertisement of this sophisticated reproductive technology in newspapers in North West India.

These advertisements had stopped last year when a petition challenging the illegality of the
advertisements was filed with the Punjab Human Rights Commission by ‘Women against
Violence’.

6
Actions required to reduce female feticide

The structures necessary for the implementation of the 1994 law have to be created at the
District level by the TamilNadu State. We have to actively mobilise volunteers to monitor the
registration and the functioning of the clinics in different Districts. Effective alliances with

ethical Doctors be made from the local levels. Test cases have to be filed against the violators.
We have to persevere with the media to highlight obstacles in the implementation of the Act and

to raise the consciousness of our society against this crime. Simultaneously we have to get
involved in actions to ensure that public at large becomes supportive of this campaign. Lobbying

with the political parties to put this issue on their agenda is imperative. All this is just one step
towards efforts to empower women in our society.
Regrettably, senior TamilNadu Govt, officials like-Ms. Sheela Rani Chungath have

generally been indifferent to female feticide unlike on female infanticide. Perhaps the formidable
political clout of the Doctors in the state could be a factor. Yes^Ms. Chungath took-interest in
one case against an erring Doctor. But the reported fear that aggressive effort to implement the
law against the Doctors would threaten women’s right to abortion is mistaken. We hope as a
member of the State Advisory Board of the Act, she will take initiative to include the

representatives of the Coalition on the panel.

Conclusion
The deterioration of women’s status and the emergence of female feticide is not an unique

sociological phenomenon confined to TamilNadu. Sadly, we have seen recently similar trends

in other parts of the country; even in diverse cultural contexts where there has been relative
greater gender equality; such as in the Uttarakhand hills or the Kashmir valley. Our challenge

in TamilNadu is to initiate a vibrant campaign against female feticide. If we all are committed

then we can reach out to the hearts and minds of our people. This can motivate social activists
and others elsewhere to launch similar campaigns against female feticide. Jammu & Kashmir
is important as it is the only state in the country where there is no legal prohibition against sex
determination testing. We are hopeful about the proposed campaign, as in the case of recognition

of female infanticide TamilNadu had set an example for the rest of the country.

The earlier campaigns in the country against sex selective abortions failed despite the
moral correctness of the issue, as they could not create a sustained social movement against the

heinous crime. To stem the increasing epidemic of female feticide we have to expose the

7
7
collusion of unethical medical practitioners with the patriarchal society. The deleterious ways

that globalisation contributes to economic marginalisation of poor women has to be highlighted

and the state be held accountable to provide relief.

The campaign has to oppose the

commodification of women in popular culture and media. Organisations and individuals with

different priorities and ideological beliefs have to come together to battle the powerful patriarchal
forces operating within the institutions of the family, government and the civil society. A

transformation of our gendered society is necessary for the elimination of female feticide.
Ackndwledgements

The staflnof S1RD. Madurai and HRF Madras for taking the initiative in organising the
Consultation and spending a considerable amount of their financial and human resources in
initiating the TamHNadu campaign. This is the first time in 20 years that any organisation has

given so much priority^ the heinous crime of female feticide in TamilNadu. Sabu’s recent work

was supported in part by

ICEF, India. I would like to thank Ms. A. Kaul, M. Gurung, S.

Rangasawmi, Mr. M. Sharm;

Professors Bhat and Kulkarni, and Dr. R. Young for their

assistance.

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■’-2

CAMPAIGN AGAINST SEX SELECTIVE ABORTION
Contact Address: 11, Kamala 2nd Street, Chinna Chokkikulam, Madurai 625 002.
Phone & Fax: 0452 2530486 e-mail: sirdmdu@hotmail.com
Chennai: No.10, Thomas Nagar, Little Mount, Saidapet, Chennai 600 015.
Phone: 044 22353503 Fax: 044 22355905

^4

Workshop on
Emerging Medical, Reproductive and Genetic Technologies
Implications for PCPNDT Act
PROGRAMME SCHEDULE

9.30 a.m.
10.00 a.m.

10.15 a.m.
11.00 a.m.

11.45 a.m.

12.30 p.m.
1.00 p.m.

Registration
Welcome & Purpose of the
workshop

Facing the
Unborn

3.15 p.m.

Ms Radhika
Co-ordinator, CASSA

Ms P Phavalam

Status of Child Sex Ratio in Tamil
Nadu

Convenor, CASSA

Challenge of the

:

Dr Gita Arjun
E.V.Kalyani Medical Centre, Chennai

Dr Samuel JK. Abraham

Benefits and Challenges of StemCell Research and its Therapeutic
Applications

Director,
Nichi-In
Centre
Regenerative Medicine, Chennai

Chennai

:

Benefits and Challenges of
and
Emerging
Reproductive
Genetic Technologies

6

for

Dr J Amalorpavanathan

Social and Ethical issues related
to Stem Cell

1.45 p.m.
2.30 p.m.

:

Dr Geetha Hari Priya
Prashanth
Chennai.

Hospital,

Multispeciality

Lunch

Cord Blood Stem Cell and its
Medical Applications

Status of Enforcement of
PCPNDT Act in Tamil Nadu

:

Dr Moorthy
Medical Director of Life Cell, Chennai

Mr M Jeeva
Director, SIRD

Ms Shantha Kumari
Member, State Supervisory Board, TN

Ms U Vasuki

4.00 p.m.

Concluding Session

Member,
Chennai

Advisory

Discussion
strategies

by

Committee,

delegates

to

plan

Time 10.00 a.m.

Date: 8.8.2006

Venue
:
J J Hall, ICSA,
,_____________ 107, Pantheon Road, Eqmore, Chennai-8

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12

Centre for Enquiry into Health and Allied Themes
2/10, Swanand, Aapli Sahakari Society, 481, Parvatidarshan, Pune - 411009
Phone : 4447866, 4443225, email: cehatpun@vsnl.com

Ref:admn//POA: OR No.173

Dear friends.

Greetings! Hope you received the background material sent to earlier on Sat, July 13, ’02.
Please find enclosed a copy of the document ‘chapter scheme and plan of analysis’. You
must have already received the soft copy of the same on Tuesday, 16 July, ’02.

Look forward to meeting you during July 20-21,’02 meeting to discuss the plan of
analysis.

With sincere regards

r

Sunita V B
Project in-charge
Abortion incidence research
CEHAT, Pune

Research Centres of Anusandhan Trust

/ XS1

kJ v\ -

DRAFT NOT TO BE QUOTED

BACKGROUND MATERIAL (PART II)
(Chapter scheme and plan of analysis)

for

The meeting of
MEMBERS OF THE RESOURCE GROUP

To discuss the plan of analysis
Scheduled on

Sat-Sun, July 20-21, 2002
At YMCA International, Mumbai Central

by the members of the project titled

ABORTION RATE, COST AND CARE:
A COMMUNITY BASED STUDY
ABORTION ASSESSMENT PROJECT - INDIA (AAP-INDIA)

Pune
July, 2002

D: \Shelley\RAI\chapters\CHAPTER SCHEME! and POA-7. doc

ABORTION RATE, CARE AND COST:
A COMMUNITY BASED STUDY

TENTATIVE CHAPTER SCHEME AND
PLAN OF ANALYSIS

FOR RESOURCE GROUP MEETING SCHEDULED
ON Sat-Sun, July 20-21, ’02 at YMCA, MUMBAI

TEAM: SUNITA, SHELLEY, BHAGYASHREE, SUGANDHA

D:\Shelley\RAI\chapters\CHAPTER SCHEME1 andPOA-7.doc

CHAPTER SCHEME OF THE RESEARCH REPORT OF THE
ABORTION RATE, CARE AND COST: A COMMUNITY BASED STUDY

TABLE OF CONTENT
•

Executive Summary

•
•
•
•
•
•

Ch I: Introduction
Ch II: Study design and research methodology
Ch HI: Profile of the study area (PSUs - primary sampling units)
Ch IV: Profile of the household/Background characteristics of the households
Ch V: Profile of the women research participants
Ch VI: Reported pregnancy outcomes (child birth, spontaneous abortions, induced abortions,
still birth)
Ch VH: Cafe sought for abortion
Ch VUI: Cost of abortion care services
Ch VH and VJU perhaps will be clubbed together as cost and care data will be have to be treated
together quite often
Ch IX: Sex selective abortions
Ch X: Summary and conclusion
References
Annexures
o Arriving at sample size: The rationale and the procedure
o Data quality (stock taking of non-sampling errors)
o Data quality (Estimates of sampling error)
o Tools of data collection
■ Area profile recorder
■ Household interview schedule
■ Women’s interview schedule

•
•
•
•
•
•
•

D:\Shelley\RAI\chapters\CHAPTER SCHEME1 andPOA-7.doc

OBJECTIVES OF THE STUDY
(for ready reference of the members of the resource group)
Aims: The overall aims of the study will be to study pregnancy outcome analytically with
a focus on rate of abortion and related issues. Further, the study will enable providing
inputs/feedback to society at large and to different stake holders including policy makers
to facilitate women’s access to safe, legal and affordable abortion care services.
Objectives: The specific objectives will be:
a) To arrive at estimates related to abortion incidence rate, such as,
■ To arrive proportion of women from reproductive age who have had at least one
abortion.
3 To arrive at estimates of rate of abortions, both spontaneous and induced.
■ To arrive at average number of abortions per woman.
b) To arrive at estimate of burden and nature of abortion related morbidity for women.
c) To document indications of /reasons for seeking abortion and to analyse the changing
pattern, if any.

d) To study women’s abortion needs in the light of their socio-cultural milieu.
e) To study women’s choice of provider to meet abortion care needs.
f) To study expenditure patterns on abortion care.

3

D:\Shelley\RATchapters\CHAPTER SCHEME1 and POA-7.doc

Chapter I

INTRODUCTION1
Chapter outline
1.1
1.2
1.3

1.4

Introduction ( about what would the chapter contain etc.)
Background and context
• CEHAT's work on abortion to date, logical linkages, conceptualization of AAP-India etc.
Review of literature (highlighting the data available on abortion incidence in India and
contextualising using data from other countries. This would include both estimates based on
extrapolations and empirical research, such as NFHS, RCH and other small-scale community based
studies.).
• International studies for global perspective
• Indian based studies for national/lccal perspective

Why rate, cost and care study?
Rationale for taking up such a study in a broader framework of women’s health care need,
household expenditure pattern vis-a-vis health care, women’s health care needs being generally a
low priority at the household level, and spending on abortion care may be further difficult because
of stigma attached to the act of abortion. There is not much available on these aspects and from this
perspective.
It will provide insights into the issue and significance of the study is also because the way its
research design is laid down which allows generalization of the findings at least at the state level.
The findings in terms of numbers will help strengthen the arguments during advocacy initiatives
designed for women right to health care in general and abortion care in particular. In addition it will
feed into theorization of various related matters and concepts in medical anthropology, such as,
models explaining health care seeking, utilization of health care services and expenditure incurred;
household production of health.

Abortion incidence as a pregnancy outcome:
Total pregnancy wastage has been studied. This lias been studied by recording the entire pregnancy
history vis-a-vis reported pregnancy outcome.

Total number of reported pregnancy outcomes has been captured in the current study. This includes

• Live births
• Living children
• Spontaneous abortions
• Induced abortions
• Still births
For team’s reference: Should be drawn from the report prepared for ECG in June, ‘01 containing detailed literature
review of methodologies, our study design and report of the ethical reviews. Members of the resource group can refer to the
Background material prepared for this meeting and sent to you, which carries relevant sections of the above mentioned report.

4

D:\Shelley\RAI\chapters\CHAPTER SCHEME1 and POA-7.doc

1.5

Aims and objectives of the study

1.6

Abortion incidence rate and other measurements

1.6

Care:
• Literature review leading to laying down the conceptual framework (which has been used while
designing the tools and will be the guiding framework for analyzing and presenting the data.
• Significance/rationale
• Care in this study is conceptualized in terms of both, medical care sought and domestic care
available for women at home during and after the event.
• Induced abortion is neithei a delivery nor an event, which in Indian cultural and social system
would fetch women care and attention. Thus, it is likely that the pattern of health care in the
context of abortion will be different than what otherwise exist.
• Similarly, the domestic care (care from members of the various social networks - household,
extended families, natal family, close kins, neighbours, friends, colleagues/co-workers at the
place of employment) may also be dependent on the situation of health c<ire needs.
• Medical care: Analytical review of health care seeking behaviour studies highhghting
determinants of choice of provider/health care facility; gender differentials; differentials as
regards type of illness, health care during delivery. The fact that abortion, both spontaneous and
induced abortion are stigmatized, although in a different way; that induced abortion is not an
illness will be important factors in the type of care sought and/or received. Other factors will
also play an important role in determining as what would be available for women seeking
abortion care.
Determinants of choice of provider could be classified as endogenous and exogenous.

Endogenous factors would be as below:
Type of abortion - spontaneous and induced
O
o Woman’s relative position in the family (occupation - type of job/housewife, decision
making in case of abortion, education, husband’s education, parity, number of sons and
daughters,
o Class (indicating economic status which determines purchasing capacity)
o Social status (caste, educational achievements of the family)
o Reasons for induced abortion
o Decision makers in case of induced abortion
o In case of spontaneous abortion, repeat incidences, if any
o Expectations and priorities of quality of care
Exogenous factors would be as below:
o Residence - urban/local
o Availability of, accessibility and approachability to health/abortion care facilities
o Cost of the treatment
o Perceived quality of care at available health care facilities/providers
o Earlier experiences and/or experiences of others

2 In tliis study, we have collected data on domestic care only in case of abortion care. Thus, comparison across different health
care situations on this parameter is not possible. However, research findings from other studies can be used, if available. They
are possible in anthropological literature.

5

D:\Shelley\RAI\chapters\CHAPTER SCHEME1 andPOA-7.doc

•

•

1.5

Often, multiple providers are tried for various reasons. This is important to study as it will on
the one hand will reveal the domestic constraints, if any; and dissatisfaction with a particular
service provider and reason for being so and/or problems in reaching to the health care facility
on the other hand. These will provide us insights into the complex interplay among various
factors and dynamics/pathways as how the determinants are at work
Laying down the conceptual framework of and perspective on health care seeking and
utilization of health care services drawing from the existing research using the understanding of
determinants of choice of provider in terms of endogenous and exogenous factors.

Cost:
• Literature review
• Significance/rationale
• Cost that women have to bear has been conceptualized in terms of both, direct and indirect
cost incurred during the abortion incidence.
• Direct cost includes the expenditure on abortion care sought either from formal abortion
service providers or informal providers; cost incurred for diagnostic, medicine prescribed
and consumed; travel cost; and also expenditure on food etc during stay at hospital if any.
Direct cost thus could be considered in to two (a) direct medical expenditure and
(b) direct non-medical expenditure incurred.

•

♦

It is also important to examine as to do women and their families or friends manage to
organize for cost of abortion care services sought and other related expenditures. The type
of organization (who from the family are supportive and provide the finances, who from the
friend etc.) of these finances will be determined by the context of abortion (in case of
induced -reasons, parity, pregnancy outcome history - number of sons and daughters and
others mentioned earlier; in case of spontaneous - whether repeat incidence along with
factors); and the socio-economic factors. We will explore whether these factors exhibit any
such relationship to demonstrate that they in reality function as the determinants of type of
organization of finances required for abortion care cost.
Indirect cost includes loss of wages of woman and her family members, and other losses
because of abortion incidence.

Graphic presentation of the conceptual framework based on the literature reviews and
perspective that is presented till now as regards care and cost - a graphic presentation.

1.6
•

Abortion related morbidities
Overview of the report
This would give in brief an overview of the chapter wise content of the report

6

D:\Shelley\RAI\chapters\CHAPTER SCHEME1 and POA-7.doc

Chapter II

STUDY DESIGN AND METHODOLOGY
Chapter Outline
(Extensive literature review is presented in the report sent to ECG. This is to be used here. Documentation
in the Reference manual to be used and also the ECG report)

2.1

2.2
2.3

2.4

2.5

2.6
2.7

Introduction
• Overview of the chapter (about the content of the chapter)
• Review of literature of methodologies used in abortion incidence study and other pregnancy
outcome studies
Selection of study area
Sampling
o Determining sample size
o Sampling procedures and method used
• Rural
• Urban
Tools of data collection
o Area profile recorder
• Objective
• Major heads of data
Household
interview schedule
o
• Objective
• Major heads of data
o Woman’s interview schedule
• Objective
• Major heads of data
Training of the field researchers/investigators
o Objective
o Content
o Method
o Duration
o Results/outcome
Pilot testing
Conduct of study
o Filling up APR
o House Esting
o Survey
• Conducting community meetings
• Objectives
® Subject matter
• Documentation
• Conducting interviews
• Seeking informed consent
• Conducting interview
• Privacy during interview

7

D:\Shelley\RAI\chapters\CHAPTER SCHEME1 and POA-7.doc

Field level editing
Team meetings
• Objective
• Method (frequency, documentation)
Composition of the team and rationale
Problems encountered
• Fetching maps from Census
• House-listing
• Establisliing rapport - urban/rural
• Maintaining privacy
Methodological issues
• Arriving at accurate age in case of non-literate women
• Capturing pregnancy outcome
• Income recording and its authenticity
• Underreporting of sex detection tests and sex selective abortions
• Underreporting of abortions
Ethical issues
• Seeking informed consent
• Maintaining privacy
• Meeting with community’s expectations
• Consequences for field investigators of
o undergoing training
o getting exposed to the ground realities vis-a-vis people’s deprived living situations, women
related issues,
o the fact that not much we could offer to help people reduce their misery
o leaving fhe institution after acquiring the sense of ‘empowered’ and having to face the
outside world including their personal lives and domestic decisions
• Review of methodology by Institutional Peer Review Committee and Institutional Ethics
Committee
•
•

2.8
2.9

2.10

2.11

8

1 \

D:\Shellfy\RAI\chapters\CHAPTERSCHEMEl andPCA-7.doc

PLAN OF DATA ANALYSIS/PRESENTATION
(contd...)

Dummy tables (Some sample formats)
Sampling of rural PSUs:
Region and
districts

Region I: Grt
B’bay, Thane,
Raigarh, Ratnagiri,
Sindhudurg______
Region II: Nashik,
Dhule, Jalgaon
Region III: Pune,
Satara, Sangali,
Solapur, Kolhapur,
Ahmadnagar______
Region IV: A’bad,
Jalna, Parbhani, Bid,
O’bad, Buldhana,
Akola, Latur,
Amravati________
Region V: Nanded,
Yawatmal,
Wardha, Nagpur
Region VI:
Bhandara,
Chandrapur,
Gadchiroli_______
State totals

Table 2.1(a) Maharashtra: Regionwise profile of rural population
% popn share in the
Of the total 100
SCST
ST
Popn excluding
Total no
state
popn
(popn
of
the
rural PSUs,
population
population
and
villages
with
less
of res
proprtionate
share
state
and
region
is
percentage
and
than
or
equal
to
hhds
of PSUs to be
excluding
those
with
total
percentage
30
resi
hhds
&
(2)
drawn from
villages with r-hhds
population
with total
total no of villages
population less than or equal to 30 respective stratum
(4)
(3)
(7)
(5)
______ (0______
5502777/48174227 =
11.42% of 100 =
107848
5502777
1226312
5527098
11.42
approx 11 PSUs
(22%)
(19.5%)
(5537)
(5860)

Total
population
& total
number of
villages
(1)

2132116 6794266/48174227 =
(31.3%) ______________ 14.10
477124 13893449/48174227 =
28.84
(3.41%)

14.10% of 100 =
approx 14 PSUs
28.84% of 100 =
approx 29 PSUs

785946
(6.2%)

12677326/48174227 =
26.3

26.3% of 100 =
approx 26 PSUs

1907279
(34%)

1046228
(18.7%)

5544198/48174227 =
11.51

11.51% of 100 =
approx 12 PSUs

1469415
(38%)

(23%)

3762211/48174227 =
7.81

7.81% of 100 =
approx 8 PSUs

6811106
(4931)
13911609
(8063)

6794266
(4726)
13893449
(7805)

2621810
(38%)
211628 (15%)

12735925
(11962)

12677326
(10411)

2616774
(20%)

5584512
(6945)

5544198 (5375)

3825351
(5226)

3762211(3873)

48395601
(42987)

48174227
(37727)

Average
27.83%

100 PSUs

9

D:\Shelley\RAI\chapters\CHAPTER SCHEME1 andPOA-7.doc

Table 2.1(b) Region and stratum-wise distribution of rural PSUs
Strata
specifications
(1)

Total popn of the
stratum
(2)

% Stratum popn
w r t total popn
of the region
(3)

Total no of
villages
(5)

Number of PSUs to be
drawn from the stratum
in PPS manner
(6)

Value of ‘n’ —
sampling
interval
(Col 5/Col 6)

CD
Region I

387216
5502777

67.72
25.24
7.04
100.00

3997
1491
49
5537

2418186
3277177
1098903
6794266

35.59
48.24
16.17
100.00

1609
2987
130
4726

1421991

10.2
22.1
______ 29.5
16.5
22.12
100.00 (100.4)

2629
2525
1764
541
346
7805

Stratum 1_______
Stratum 2_______
Stratum 3_______
Region I totals
Region II

3726910

Stratum 1_______
Stratum 2_______
Stratum 3_______
Region II totals
Region DI

Stratum 1_______
Stratum 2_______
Stratum 3_______
Stratum 4_______
Stratum 5_______
Region III totals

11
Ijoouj1

3067615
4100783
2229792
3073268
13893449

Total PSUs to be drawn
from Region 1 = 11
67.72 of 11 =8(7.48)
25.24 of 11 =3(2.75)
7.04 of 11 =1 (0.77)
__________________ 12
Total PSUs to be drawn
from Region II = 14
35.6% of 14 = 5(4.98)
48.2% of 14 = 7(6.72)
16.2% of 14 = 2(2.3)
__________________ 14
Total PSUs to be drawn
from Region IH = 29
10.2%of29 = 3(2.9)
22.1 %of29 = 6(6.4)
29.5 % of 29 = 9 (8.7)
16.05 %of29 = 5 (4.64)
22.12 %of29 = 6 (6.38)
29

Value of‘n’ —
sampling interval
(Based on population
-PPS)
(Col 2/Col 6)
(8)

3997/8 = 500 3726910/8 = 465863.75
1491/3 = 497 1388651/3 = 462883.66
387216/1 =387216
49/1 = 49

1609/5 = 322
2987/7 = 427
130/2 = 65

2418186/5 = 483637.2
3277177/7 = 4681.57
1098903/2 = 549451.5

1421991/3 = 473997
2629/3 = 876
2525/6 = 420 3067615/6 = 511269.16
1764/9 = 196 4100783/9 = 455642.55
541/5 = 108 2229792/5 = 445958.4
346/6 = 58 3073268/6 = 512211.33

D:\Shelley\RAI\chapters\CHAPTER SCHEME1 and POA-7.doc

Region IV
Stratum 1
Stratum 2
Stratum 3
Stratum 4
Stratum 5
Region
Totals
Region V

IV

2404339
4134398
3339519
1380592
1418478
12677326

18.96
32.61
26.00
10.89
11.12
100.00 (99.58)

4797
3565
1536
338
175

Stratum 1_______
Stratum 2______
Stratum 3_______
Region V Totals
Region VI

1869961
3119679
554558
5544198

100.00

1807
3498
70
5375

Stratum 1
Stratum 2
Stratum 3
Region
Totals
Totals

1189098
2212449
360664
3762211

________ 31.61
58.81
9.59
100.00 (100.01)

1094
2732
47
3873

VI

33.73
56.26
10.00

Total PSUs to be drawn
from Region IV = 26
18.96% of 26 = 5 (4.9)
32.61 %of26 = 9(8.5)
26.00% of 1536 = 7(6.8)
lC.89%of26 = 3(2.9)
~ 11.12% of 175=3(2.9)
27
Total PSUs to be drawn
from Region V = 12
34% of 12 = 4(4.1)
56% of 12 = 7(6.7)
10% of 12= 1 (1.2)
__________________ 12
Total PSUs to be drawn
from Region VI = 8
32% of 8 =3 (2.56)
59 % of 8 = 5 (4.7)
10% of 8 =1(0.8)
9

4797/5 = 959 2404339/5 = 480867.8
3565/9 = 396 4134398/9 = 459377.55
1536/7 = 3339519/7 = 477074.14
338/3 = 113 1380592/3 = 460107.33
1418478/3 = 472826
175/3 = 58

1807/4 = 452 1869961/4 = 467490.3
3498/7 = 500 3119679/7 = 445668.4
554558/1 = 554558
70/1 = 70

1189098/3 = 396366
1094/3 = 365
2212449/5
= 442489.8
2732/5 = 546
47/1 = 47
360664/1 = 360664

103 PSUs

11

D:\Shelley\RAI\chapters\CHAPTER SCHEME1 and POA.-7.doc

Table 2.1(c) Profile of the selected rural PSUs in comparison to the state profile
C haracteristics/ parameter

Size of the
villages

> Villages with 31-149 resi hhds

> Villages with 150-299 resi hhds
> Villages with 300-599 resi hhds
> Villages with 600-999 resi hhds
> Villages with more or equal to 1000 resi hhds
Total___________ _______________ ______
SCST popn and > Villages with SCST popn less than 25% and
size of the
resi hhds less than 1000
village
> Villages with SCST popn more than or equal to
25% and resi hhds less than 1000__________
> Villages with resi hhds more than or equal to
1000, regardless of SCST popn___________
Totals

For the Selected 103
Rural PSUs
26 (25.2 %)

For the State of
Maharashtra (Rural)
17348(46.0%)

32(31.1 %)
21 (20.4 %)
10 (9.7 %)
14(13.6%)
103 (100.00%)
60 (58.3%)

12281 (32.6%)
5844 (15.5%)
1437(3.8%)
817(2.2%)
37727 (100.00%)
21977(58.3%)

29 (28.2%)

14933 (39.6%)

14(13.6%)

817(2.2%)

103 (100.00%)

37727 (100.00%)

77

D:\ShdUy\RAI\chapUr^CHAPTER SCHEME1 andPOA-7.doc

Sampling of urban PSUs
Table 2.1(d) Maharashtra: Regionwise profile of urban population
Region and districts

Region I: GrtB’bay,
Thane, Raigarh,
Ratnagin, Sindhudurg
Region II: Nashik,
Dhule, Jalgaon
Region HI: Pune, Satara,
Sangali, Solapur,
Kolhapur, Ahmadnagar
Region IV: Aurangabad,
Jalna, Parbham, Bid,
O’bad, Buldhana, Akola,
Latur, Aniravati________
Region V: Nanded,
Yawatmal, Wardha,
Magpur______________
Region VI: Bhandara,
Chandrapur, Gadchiroli
State totals

Total
population &
total number
of wards
(1)
13848944
(1082)

Cannt popki
and wards
(2)

2763595
(1069)
5664208
(1704)

44331
___ (7)
219577

Population & total Total number of
number of wards
resident hhds
Without CANTT
(4)
POPN
(l)-(2) = (3)
NIL
13848944
(1082)

% popn share in the
Of the total 100 urban
state popn
PSUs, proprtionate share of
PSUs to be drawn from
(5)
respective stratum
__________ (6)___________
13848944/2985085
46.39% of 100 = approx
3= 46.39
46 PSUs

(27)

2719264
(1062)
5444631
(1677)

2719264/29850853
__________ =^9.11
5444631/29850853
= 18.24

9.11% of 100 =
approx 9 PSUs
18.24% of 100 =
approx 18 PSUs

4034981
(1835)

19437
(7)

4015544
(1828)

4015544/29850853
= 13.45

13.45% of 100 =
approx 14 PSUs

2999530
(975)

8559
(5)

2990971
(970)

2990971/29850853
= 10.02

10.02% of 100 =
approx 10 PSUs

840058
(382)
30151316
(7047)

NEL

840058
(382)
29850853
(7001)

840058/29850853
= 2.81

2.81% of 100 =
approx 3 PSUs
100 PSUs

300463
(46)

13

D:\Shelley\RAI\chapUrs\CHAPTER SCHEME1 andPOA-7.doc

Table 2.1(e) Region and stratumwise distribution of urban PSUs
Total no of
wards
(5)

Total popn of
the stratum and
number
of
wards
(2)

% Stratum
popn w r t
total popn of
the region
(3)

11743837(223)

84420 (60)
2020687 (799)
13848944 (1082)

84.8
0.61
14.6
100.00

Stratum 1 (SS)_________
Stratum 2 (DQ)________
Stratum 3 (Other towns)
______ Region II totals
Region III

NIL
1177435 (183)
1541829 (879)
2719264 (1062)

NIL
43.3
56.7
100.00

Stratum 1 (SS)_________
Stratum 2 (DQ)________
Stratum 3 (Other towns)
_____ Region III totals
Region IV

1566651 (85)
1480301(221)
2397679 (1371)
5444631 (1677)

28.8
27.2
44.0
100.00

221
1371
1677

Stratum 1 (SS)________
Stratum 2 (DQ)_______
Stratum 3 (Other towns)
Region FV Totals

NIL
2118750(373)
1896794 (1455)
4015544 (1828)

NIL
52.8
47.2
100.00

373
1455
1828

Strata specifications
(1)

Region I
Stratum 1 (SS)_________
Qfrahini O
UUUVUllI

Stratum 3 (Other Towns)
_______ Region I totals
Region II

223
60
799

183
879
1062

Number of PSUs to be
drawn from the stratum
in PPS manner
(6)

Total PSUs to be drawn
from Region I = 46
84.8%of46 = 39 (39.01)
0.61% of 46= NIL (0.28)
14.6% of 46 = 7 (6.7)
__________________ 46
Total PSUs to be drawn
from Region II = 9
NIL
43.3% of 9= 4(3.9)
56.7% of 9= 5(5.1)
___________________ 9
Total PSUs to be drawn
from Region III = 18
28.8% of 18 = 5(5.2)
27.2% of 18 = 5(4.9)
44.0% of 18 = 8(7.9)
__________________ 18
Total PSUs to be drawn
from Region IV = 14

52.8% of 14= 7(7.4)
47.2% of 14 = 7(6.6)
14

Value of ‘n’ - sampling
interval
(Col 2/Col 6)
(7)

11743837/39 = 30112
84420/- = 0
2020687/7 = 288669.57

NIL
1177435/4 = 294359
1541829/5 = 308366

1566651/5 =313330
1480301/5 = 296060
2397679/8 = 299710

NIL
2118750/7 = 302678.6
1896794/7 = 270971

D:\Shdley\RAI\chapUrs\CHAPTER SCHEME1 andPOA-7.doc

Region V
Stratum 1 (SS)_______
Stratum 2 (DQ)______
Stratum 3 (Other towns)
Region V Totals
Region VI

1624752 (75)
486646 (93)
879573 (802)
2990971 (970)

54.3
16.3
29.4
100.00

75
93
802
970

Stratum 1 (SS)_______
Stratum 2 (DQ)______
Stratum 3 (Other towns)
Region VI Totals

NIL
327483 (112)
512575 (270)
840058 (382)

NIL
38.98
61.02
100.00

112
270
382

Totals

Total PSUs to be drawn
from Region V = 10
54.3% of 10 = 5(5.4)
16.3% of 10= 2(1.6)
29.4% of 10= 3 (2.9)
__________________ 10
Total PSUs to be drawn
from Region VI = 3
NIL
38.98 %of3 = 1(1.17)
61.01 % of 3 = 2(1.83)
3
Total Urban PSUs = 100

1624752/5 = 324950.4
486646/2 = 243323
879573/3 = 293191

327483/1 = 327483
512575/2 = 256288

15

D:\Shelley\RAI\chapiers\CHAFTER SCHEME1 and POA-7.doc

Study area
Table 2.3a Regionwise r epresentation of the districts in the sample

Regions

Region I

__________ Represented in the sample survey
Districts titles
Tehsils titles
Total number of Villages
(rural PSUs)
District 1

District 2

Region K
Region IK
Region IV
Region V
Region VI

Table 2.3b Regionwise representation of the districts in the urban sample

Regions
Districts

Represented in the sample survey
Tehsils
Total number of Wards

Region I
Region II
Region IK
Region IV
Region V
Region VI
Table 2.4 Response rate pattern: A Summary

Location/resi
dence
Rural_______
Urban
_______ Total
Location

Rural_______
Urban______
_______ Total
Location

Number of
sampled units
(a)
103
100

Number of units
included
(b)
103
100

No Response rate

Number of
sampled units
(a)

Number of units
included
(b)

No Response rate

Number of
sampled units
(a)

Number of units
included
(b)

No Response rate

0%
0%

Rural_______
Urban______
Total

16

D:\SheUey\RATchapters\CHAPTER SCHEME1 andPOA-7.doc

Response rate pattern at Household level:
o Household could not be accessed
o Locked
o Eligible person not available to respond to the protocol
O
Refused to participate in the study (before reading out letter of introduction)
o Reason 1
o Reason 2
Type of informed consent
o Written
o Verbal
o Refused to participate after reading the letter of introduction
Status of the interview
o Complete
o Incomplete because of withdrawal half way through
■ Reason 1
■ Reason 2
Response rate pattern among the eligible women:
o Could not meet woman
o Reason 1
o Reason 2
o Refused to participate in the study (before reading letter of introduction)
o Reason 1
o Reason 2
Type of informed consent
o Written
o Verbal
o Refused to participate after reading the letter of introduction
Status of the interview
o Complete
o Incomplete because of withdrawal half way through
■ Reason 1
■ Reason 2
Responses to our methodological approaches and strategies,
which were aimed at making it
women sensitive and ethically sound
o Data related to community meetings

Cross tabulations:
• Variation pattern across
• urban/rural;
• Greater Bombay /other urban
• Tribal/non-tribal communities
will be explored for all of the above m entioned aspects.

17

D. \Shelley\RAI\chiipters\CHAPTER SCHEME! andPOA-7.doc

ANALYTICAL CATEGORIES TO BE USED
The chapters hereafter will be the data based ones. Before we begin presenting the plan of data analysis
and the patterns of their presentations, it is useful to have a glance at the kind of system of variables that

we visualise for the purpose of analysis.
Analytical categories are primarily the concepts/variables, which explain the variation in the data on a
articular concept. There will be basic analytical categories and intermediate categories of the variables
that will be used. Thus, the basic analytical categories are treated as independent variablesi to explain
the variation in tlie dependent variables. In a way, these are ‘given’. No other vanable or a
can explain these variables. For example ‘caste’, ‘ religion’ and may other demographic vanables mil
fall into this category.

On the other hand the intermediate variables at a time are both explanatoiy and dependent. They will be
‘dependent’ on some or all variables considered as basic analytical categones in a particular research
and at the same can explain some of the impact variables. For example, avaihbihty of and access to
health care facilities would depend upon residence and at the same they will also explain women s
choice of abortion care facilities.

In the present study we will also be using both types of variables namely (a) single individual vanables
and (b) and composite variables. The latter will represent broader conceptual categones emerging from
conceptual framework of the study. They further explained under the respective sub-head in this

section.
The basic analytical categories will be mostly single variable type. Intermediate vanables/analytical

categories can be either single or composite variables.
Thus the system of variables for the present study would be as below:

Analytical categories

Basic
(Independent/
Explanatory)

Single

Intermediate
(Independent and dependent)

Single

Composite

Impact
(Dependent)

Single

Composite

The various categories of variables are explained below along with rationale in brief.

18

D:\Ghelley\RAI\chapiers\CHAPTER SCHEME1 and POA-7.doc

BASIC ANALYTICAL CATEGORIES
Some of the basic analytical categories are as below:

•

Place of residence/location
• Urban/rural
• Region (to explore if there are any variations in data trends over the regions. May be useful only
in certain variables/concepts)
The rationale: Availability of and access to health care facilities vary across these parameters.
Characteristic of population

• Tribal/non-tribal
The rationale: It is hypothesised and preliminaiy impressions based on the patterns of data indicate
that practices of the members of the tribal community as regards, use of contraceptives and related
matters differ from the non-tribal population.

Demographic variables (individual level)
• Age
• Sex
• Marital status
•

Socio-economic parameters (individual and Hid level)
• Economic status (income data)
• Education
• Occupation
The rationale: Broadly speaking, use of contraceptives, type of care accessed, type of domestic care
available and availed are likely to be detennined by these parameters.

•

Community identities (individual and hhd level)
• Caste
• Religion
The rationale: Will be used to examine and explore if there are variations across these variables
only in case of certain analysis. For example: Family size, reported induced abortions, reasons for
undergoing abortion, practices related to contraception.

The above mentioned basic variables will be the most frequently used in the present study and will be
used in the analysis of data on all the aspects presented in different chapters of the present report.
As we actually start working with data once basic operations as regards data files are completed and data
are cleaned and validated.

INTERMEDIATE ANALYTICAL CATEGORIES OF VARIABLES
Some of the intermediate analytical categories are as below:
In the context of utilisation of health care services:
c Availability of, accessibility and approachability to health care facilities
• People’s expectations of quality of care
• People’s purchasing capacity (?)
• Cost of care
• V/oman’s position in her family

In the context of cost of care:
Quality of care

19

D:\Shelley\RAl\chapters\CHAPTER SCHEME1 cu\dPOA-7.doc

COMPOSITE ANALYTICAL CATEGORIES/CONCEPTS VARIABLES
As mentioned earlier some relevant composite variables will composed/constructed based on broader
concepts relevant to the present study. These then could be used as independent/explanatory variables
and/or impact variables in analysing and examining data. Constructing indices is an useful exercise for
two reasons (a) it allows systematic operationalisation of the theoretical concepts constituting the
conceptual model forming the foundation of the research, and 0?) it allows compact and meaningful
analysis and presentation of the data without loosing on contribution of the nuanced factors/data
items/information.

Indices will be constructed using either of the following methods:
(a) By simple summation of scores if various different variable contributing to the concept/index if all
the constituents variables are theoretically of same weightage in terms of their importance.
(b) In case it is not so, factor analysis will be used to find the relative weightages to be given to the
constituent variables before they are clubbed to form composite indices. This will be done using
SPSS package.
Method (a) is simpler and straight forward whereas method (b) involves a little complex statistical
procedures to be applied before the indices are constructed. However, both are considered to be equally
sound from technical/statistical point of view. Application of different methods for arriving at indices is
An attempt will be made to construct the following composite indices. There is potential for some more
relevant indices. They all will be constructed based on concepts that we are using.
PSU level indices
o Village development index
o Availability of the basic minimum health care facilities
Household level indices
o Socio-economic status
o Life style index
Individual level indices
o Woman's relative position in the family
o Husband’s relative position in the family
Care
• Medical care
• Domestic care
Cost
• Direct cost
• Indirect cost

20

n

D \Shelley\RAl\chapters\CHAPTER SCHEME1 andPOA-7.doc

Chapter III
PROFILE OF THE STUDY UNITS
(Data from the area profile recorder - APR - to be used)
Chapter Outline
3.1

3.2
3.3

Introduction to the chapter (one/two para)
• About the chapter
• Rationale/objective of getting these data
Methodology used to obtain data using APR and the major information heads
(tills will either be presented in the ‘Methodology’ chapter or here in this chapter)
Profile of the PSUs

3.3.1
•
•
•
•
3.3.2
3.3.3
3.3.4
3.3.5
3.3.6
3.3.7
3.3.8

General
Total Area (range, mean, mode, classified categories based on percentiles)
Total Population (range, mean, mode)
Total number of Resident Households (range, mean, mode)
Number of household below poverty line
Caste composition
Religion
Access to transportations
Access to basic amenities (water, electricity, sanitation)
Access to educational facilities
Access to health care facilities
Availability of basic minimum health care facilities

Plan of data analysis
3.3 Profile of the PSUs

This mostly will be based on the descriptive statistics to lay down profile of the study units as
regards some basic background characteristics.
3.3.1

General profile
• Total Area (range, mean, mode, classified categories based on percentiles) (APR: 201)
• Total Population (range, mean, mode) (APR: 202)
• Total number of Resident Households (range, mean, mode) (APR: 203)
• Number of hhds below poverty line (APR: 204)

3.3.2 Caste composition (APR: Section 2)
• Dominant castes (APR: 208)
• Co-dominant castes (APR: 209 - 210)
3.3.3 Religion (APR: Section 2)
• Dominant religion (APR: 205)
< Co-dominant religion (APR: 206)

21

D: \Hlielley\RAI\chapters\CHAPTER SCHEME1 and POA-7.doc

3.3.4 Access to transporation (APR: Section 3)

•

Connectivity to the outside world • Transport facilities - by road (APR: 301 to 304)
• Transport facilities - by railways (APR: 305 to 306)

3.3.5 Access to basic amenities (APR: Section 4)
•

Water (APR: 402 -405)
• Main source of water
• Availability of water round the year
• Shortage of water during the last five years
• Source of water during the shortage

•

Electrification of the community (APR: 401)

•

Sanitation (APR: 406, 407)
•
•

Drainage facilities for the majority
Type of toilet facilities for the community

3.3.6 Access to educational facilities (APR: 6.A)
3.3.7 Access to health care facilities (APR: 6.B)

•
•
•
•

Institutional health care facilities (APR: 609 - 6.19)
Availability of diagnostic facilities, such as, X-Ray, urine test, sonography (APR: 620-622)
• Located at - within the PSU area /away - specific place
Health care service providers (APR: 601 - 608)
Availability, at the nearest HCF, of ambulance and access to it when needed by the
community (APR: 623 - 624)

3.3.8 Availability of basic minimum health care services (APR: 6.C)
• Delivery by trained dais using the kit (APR: 625)
• Availability of TT vaccine and iron tablets during pregnancy (APR: 626)
• Availability at Sub-centre for treatment and medicines for common and simple illnesses
(APR: 627)
• Availability of necessary medicines at PHC at free of cost (APR: 628)
• Availability of doctor at PHC on the week days round the clock (APR: 629)
• Availability of delivery care for routine type of cases (APR: 630)

A composite variable/index could be constructed to represent the concept of availability of the
basic minimum health care services. For example - all of die above are equally important and
thus need not be weighted. Simple adding of the scores would give us the composite index. The
three point scale will be 1 ‘all the basic health care facilities available’, 2 ‘only some arc
available - if less than all 6’, 3 ‘none’.
Cross tabulations:
• Variation pattern across
• urban/rural;
• Greater Bombay /other urban
will be explored for all of the above mentioned aspects.

22

D:\Shelley\RAI\chapiers\CHAPTER SCHEELE1 andPOA-7.doc

Dummy tables (Some sample formats)
Table 3.1 Profile of the Primary Sampling Units (PSUs) - villages and urban blocks
_____________ Area, population, number of hhds, caste and religion
Urban total
Residence
Total
Residence
Variables
(freq
&
%)
(freq and %)
Rest urban
Gr Bombay
Urban
Rural
Area*

Population*

Total number of
hhds*

Dominant
Castes
• Upper caste

Co-dominant
castes
• Upper caste

Religion
• Hindu
•

Muslim

•
•

Christian
Others

* Classified categories defined based on the percentiles

23

D:\Shelley\RAr\chapters\CHAfTER SCHEN'IEl and POA~7.doc

Dummy tables
Table 3.2 Profile of the Primary Sampling Units (PSUs) - villages and urban blocks
Basic amenities
Variables

Residence

Total

(freq and %)
Urban

Rural

Urban total

Residence

(freq & %)
Gr Bombay

Rest urban

Transport
facilities by road
• At 0 distance
• At less than 5
kin
• At more than 5
km
Transport
facilities
by
railways
• At 0 distance
• At less than 5
km
• At more than 5
km_________
Water
Main Source of
water

Availability of
water round the
year
• Yes

• No
Shortage of
water during the
last five years
• Yes
• No

Source of water
during shortage

Electricity
• Yes
• No
Sanitation
Drainage
• Open

Toilets

* Classified categories defined based on the percentiles

cont..
24

D:\Shelley\RAI\chapters\CHAFTER SCHEMEI andPOA-7.doc

cont..
Variables

Residence
(freq and %)
Urban
Rural

Total

Residence
(freq & %)
Gr Bombay
Rest urban

Urban total

Access to
educational
facilities
• Primary
• Middle
• College

Access to health
care facilities
(available)
• 601
• 602

• 603
• 604
• 605________
Availability of
health care
service
providers
• 607
• 608

• 616

25

D:\Shelley\RAI\chapters\CHAPTER SCHEME1 andPOA-7.doc

Chapter IV
PROFILE OF THE SAMPLED HOUSEHOLDS AND HOUSEHOLD
POPULATION
(Data from the Household Interview Schedule to be used)
Chapter Scheme
4.1

Introduction to the chapter
• About the content of the chapter (soil of an overview of the chapter)
• Perspective

4.2

Profile of the sampled households (hhd as unit of analysis)
4.2.1 Household composition
• Composition of the hhd
• Family size
• Family type
• Sex composition
4.2.2 Access to basic amenities (water, fire wood, sanitation etc.)
4.2.3 Socio-economic profile
• Assets
• Family income and sources
• Type of grains consumed and its adequacy
• Highest level of education achieved in the hhd
• Occupation (? - perhaps can be presented in the ‘individual level analysis alone)

4.3

Profile of the sampled population (individuals as unit of analysis)
• Demographic profile
• Socio-economic profile

4.4

Health care (hhds as units of analysis) (this may be an independent chapter also can be
place before the chapter on abortion care, that is Chap VII)
• Health care needs
• Choice of provider and rationale

Plan of data analysiis
Analysis will be done at two levels as below:
■ HHD level
■ Individual level since family members from the selected household constitutes the sampled
population. This constitutes denominator for some of the measurements of pregnancy
wastage.

26

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4.2 PROFILE OF THE SAMPLED HOUSEHOLDS
(hhd as a unit of analysis)
4.2.1

Household composition
o Charactenstics of heads of households
• Caste - head of the hhd (HHD: 702)
• Religion - head of the hhd (HHD: 701)

•
•
O

O

Sex of the head of the hhd (HHD: 201 and 203)
Age of the head of the hhds (HHD:

Family size (range, mean, mode)
• Number of usual members
• Number of visitors
Family type (using the data in HHD: 204 - relation to head of the hhd)
Sex composition of hhds (data from HHD: 203)
• Equal number of men and women
• Men more than women
• Women more than men

Cross tabulations:
• Variation across urban/rural and Greater Bombay/rest of the urban will be examined
for all of the above variables.

4.2.2

Access to basic amenities (HHD: 3)
• Water
• Source (HHD: 301)
• Ownership of the source (HHD: 302)
• Distance of water source ((HHD: 303)
• Labour involved in fetching water (HHD: 304-305)
• Labour expended by (HHD: 306)
• Men
• Women
• Both
• Servants/helpers
• Others
• Fire wood (HHD: 308 - 312)
• Type of fire wood
• Source
• Distance
• Means of fetching
• Time involved
• Labour involved
• Labour expended by
• Place for bathing (HHD: 314)
• Toilet facility (HHD: 315)

Cross tabulations:
• Variation across urban/rural and Greater Bombay/rest of the urban will be examined
for all of the above variables.

27

D:\Shelley\RAI\chapters\CHAPTER SCHEME1 andPOA-7.doc

4.2.3

Socio-economic indicators
• Assets
• Ownership of house (HHD: 501-502)
• Type of house (HHD: 503 - 505)
• Land ownership (HHD: 506 - 508)
• Live stalk (HHD: 509- 511)
• Ownership of other assets (HHD: 513)

•

•

•
•
•

Standard of living index (composite index will be formed using the data on ownership of
assets) (HHD: 513.1 to 513.19, 517)

Family income (HHD: 617 - classified categories based on percentiles to be used)
o Sources of income other than main and subsidiary occupation (HHD: 511, 514, 515, 615,
616)
Highest level of education - best achieved (HHD - 207)
Occupation - (HHD: 603, 606) (perhaps can be presented in ‘individual analysis only).
Grains consumed and adequacy of food (HHD: 4)
• Type of grains consumed and source (401)
• Number of meals taken per day (HHD: 403, 404)
• Men
• Women
• Availability of adequate food round the year (HHD: 406)
• Number of days/months in a year when there is shortage of food (HHD: 406)

This is primarily to examine whether tlie families are surviving only at tlie subsistence
" level.
Cross tabulations:
• Variation across urban/rural and Greater Bombay/rest of the urban will be examined
for all of the above variables.

4.3 PROFILE OF THE HOUSEHOLD POPUATION
(individuals as units of analysis)

In this, data at individual members of the hhd/family will be used. Sampled population will be treated as
denominator for analysis.

4.3.1

Demographic profile
• Age distribution (classified categories using percentiles) (HHD: 205)
• Marital status (HHD: 206)
• Second marriage (HHD: 208)
• Sex composition of the sampled population (HHD: 203)

Cross tabulations:
• Variation across urban/rural will be examined for all of the above variables.
• Marital status will be seen across the age (classified categories) for men and women in urban
and rural area (FOUR way table)
• Second marriage by sex
• Sex composition across age (classified category) in urban and rural area (three way table)

28

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4.3.2

Socio-economic profile

•
•
•

Individual income (classified categories will be defined based on the percentiles)
Education (classified categories)
Occupation (classified categories)

Cross tabulations:
• Variation across urban/rural will be examined for all of the above variables.
• Education across age (6-17 years) for men and women in rural and urban area (four way
table)
• Education across caste and religion
• Education by occupation for men and women in rural and urban area (four way table)

4.4 HEALTHCARE
(household as unit of analysis)

4,4.1
4.4.2

4.4.3

4.4.4

General health care needs
• Type of illnesses
Choice of provider and rationale
• Utilisation of type of health care facilities in general
• Reasons for choosing them
Type of illnesses/morbidity (reference period of the last one month)
• Minor
• Major
Choice of provider (reference period of the last one month)
• Type of health care facility utilised
• Reasons for choosing a particular facility

Cross tabulations:
• Variation across urban/rural and Greater Bombay/rest of the urban will be examined for all of
the above variables.
• Choice of provider by availability of health care facilities, socio-economic status

29

D: \Shelley\RAI\chapters\CHAPTER SCHEME1 and POA- 7. doc

Chapter V

PROFILE OF THE WOMEN RESEARCH PARTICIPANTS
(Women research participants as units of analysis)

5.1
5.2
5.3

Chapter Scheme
Introduction (about what the chapter contains, perspective and relevance).
Demographic profile
Socio-economic profile

Plan of data analysis
5.2

Demographic profile

•
•
•
•

Age distribution (classified categories using percentiles) (HHD: 205)
Marital status (HHD: 206)
Second marriage (HHD: 208)
Age at first marriage (WS: 218)

o
•

Husband’s age (W81 HHt? i
Difference between age between husband and wife at marriage

•
•

Religion (WS: 202)
Caste (WS: 203)

Cross tabulations:
• Variation across urban/rural will be examined for all of the above variables.
• Marital status will be seen across the age (classified categories) for men and women in urban
and rural area (FOUR way table)
• Sex composition across age (classified category) in urban and rural area (three way table)
• Age at marriage to be crossed with current age in urban and rural areas (three way table)
• Age at first marriage by caste and religion in urban and rural area (three way table)
• Age at first marriage by education in rural and urban area (three way table)
5.3
•
•
•
•

Socio-economic profile

Individual income (classified categories will be defined based on the percentiles) C H H b. bcrv
Education (classified categories)
Husband's education (classified categories)
Occupation (classified categories)

Cross tabulations:
• Variation across urban/rural will be examined for all of the above variables.
• Education across age (6-17 years) for men and women in rural and urban area (four way
table)
• Education across caste and religion
• Education by occupation for men and women in rural and urban area (four way table)

•

Woman’s position in her domestic sphere
• Number of children, parity of her husband in the family, number of years of marriage, husband’s
education and occupation in relation to others, especially male members, woman's occupation,
education, sons (ideas for constructing such an index in a meaningful way are being explored.).

30

D:\Shelley\RArchapters\CHAPTER SCHEME1 and POA-7.doc

Chapter VI

REPORTED PREGNANCY OUTCOME
Chapter Scheme
This is to see the extent of pregnancy wastage in terms of induced and spontaneous abortions and
examine the patterns across various variables such as, demographic, socio-economic variables,
residence, practice of contraceptives, birth order. This, thus, will also help construct the context around
women’s conceptions and wastage for the population under study from the data. This insightful
construction of the context will also enhance understanding of the pregnancy wastage. We, perhaps, will
be in position to understand the interplay among various important factors, which otherwise are difficult
to capture.

Unit of analysis will be ‘pregnancy outcome’ as well as ‘women’. Denominators would change
depending on measures and type of analysis. Thus, in addition to pregnancy outcome and women, the
household population may also be a denominator. For example, pregnancy wastage per 1000 population
uses population as the denominator; pregnancy wastage per woman with age 15-55 uses women with
age 15-55 as the denominator; percentage proportion of induced abortion of tlie total live births and of
total wastage uses total live births and total pregnancy wastage respectively as denominators.

6.1
6.2

Introduction (about the content of the chapter, perspective, purpose, data from earlier
research)
Fertility
6.2.1

6.3

Reported conceptions (this will take into account all the reported conceptions regardless
of their outcome) C
’ 32• Fertility pattern
• Living children and related measurements regarding fertility.
• Space between subsequent conceptions £ W £* 3
• Age of the mother at first conception/delivery and the last conceptions/delivery
StuJ)
• Number of years of marriage at the first conception C L^>*

Pregnancy wastage

Reported induced abortions: Profile and the context of reproductive history
• Summary (no of ind abortions recorded and variations across relevant parameters)
• Reported reasons
• Length of gestation at the time of abortion (2
• Parity
k
• Number of children and sex composition <2^*
• Followed by sterilization CV3 i
10
• Followed by use of contraception
0
\
• Nth/Repeat abortion or first abortion Cw
°
• Age at each of abortion CtO » 31
• Time gap between two consecutive abortions (in case of multiple abortions)
6.3.2 Spontaneous abortions
• Perceived reasons QL3 S ’ 3 S
• Length of gestation at the time of abortion Q
• Parity'
CO S1 'i )
ClifJ
• Number of children and sex composition (2^ *
• Followed by sterilization ( uo ®
H

6.3.1

a

.

31

D:\Shelley\RAI\chapters\CHAPTER SCHEME1 andPOA-7.doc

• Followed by use of contraception Mi \
• Nth/Repeat abortion or first abortion £
6.3.3 StUl births
• Length of gestation at the time of abortion
• Parity Q blS *
)
• Number of children and sex composition f
• Followed by sterilization
« SH)
• Followed by use of contraception C
' 3 /1)
• Nth/Repeat still birth ( GOS * b\
£0Q

1

.
£61)

3oS J
r

Plan of data analysis

6.2 FERTILITY
(All the women research participants and population studied would form the denominator. Also as
stated in beginning of the chapter, total number of pregnancies, and different types of outcomes will also
form the denominatoi's depending upon the type of measurements)

6.2.1 Reported pregnancies: A Summary
♦
•

Total reported pregnancies (TRP)
Live births (LB) Q udS *,
)

1 S"

^3

6.2.2 Reported conceptions/pregnancies
• Fertility pattern: Total number of reported pregnancies by
• Individual level parameters
• Woman: age (classified categories), education, occupation, income, her position in
the hhd (the composite index)
• Husband: education, occupation, income, his position in the hhd (composite index)
• Couple: contraceptive practices
• Hhd level parameters:
• Socio-economic status (the composite index )
• hhd achievements (highest achieved education, occupation),
• tribal/non-tribal, religion
• Other parameters
• Residence- rural/urban, region
• Comparison with data from others sources of data.
• Living children and related measurements regarding fertility, such as, average children per
woman, mean number of children per woman, fertility rate for the population by
• Individual level parameters
• Woman: age (classified categories), education, occupation, income, her position in
the hhd (the composite index)
• Husband: education, occupation, income, his position in the hhd (composite index)
• Couple: contraceptive practices
• IHid level parameters:
• Socio-economic status (the composite index)
• hhd achievements (highest achieved education, occupation),
• tribal/non-tribal, religion
• Other parameters
• Residence- rural/urban, region,
• Pregnancy order by women’s age (single yr and classified)
32

D:\Shelley\RAI\chapters\CHAPTER SCHEME1 and POA-7.doc

•

•

•
•
•

Sex composition by
• Individual level parameters:
• Woman: Women’s (mothers) education, occupation; her position and status in the hhd
(the composite index), birth order
• Husband: education, occupation, income, his status in the hhd (the composite index),
• Hhd level parameters:
• Socio-economic status (the composite index )
• hhd achievements (highest achieved education, occupation),
• tribal/non-tribal, religion
• Other parameters
• Residence- rural/urban, region
Space between consecutive conceptions (WS: to be calculated using 312d/313 for two
subsequent conceptions/deliveries)
Age of the mother at first conception/deliverv and the last conceptions/ delivery (WS: 312d,
313) by
Hie composite indices at both individual (woman and her husband) and hhd level
• Residence
Number of years of marriage at the time of the first pregnancy
• The composite indices at both individual (woman and her husband) and hlid level
• Residence

6.3 REPORTED PREGNANCY WASTAGE
(All the women research participants and population studied would form the denominator. Also as
stated in beginning of the chapter, total number of pregnancies, and different types of outcomes will also
form the denominators depending upon the type of measures are being calculated)

6.3.1

Reported pregnancy wastage: A summary (reported pregnancy outcome, number of women
and total population as the denominators for various different measures).
• Induced abortion (IA)
• Spontaneous abortion (SA)
• Still births (SB)
• Proportion of women who have had experienced abortion - induced/ spontaneous - at least
once
• Average induced abortion per woman age 15-55
• Average spontaneous aboifion per woman age 15-55
• Average still births per woman age 15-55
• Induced abortion rate per 1000 population
• Spontaneous abortion rate per 1000 population

Cross tabulations: Variation across
• urban/rural
• tribal/ non-tribal population
• caste, religion will be examined for all of the above variables.
• life time and reference period
Multivariate analysis:
• Life time/reference period in urban and rural; and Gr Bombay and the rest of the urban (three
way table).
• Comparison of induced abortion rates and fertility rates across urban/rural; tribal/non-tribal

33

D:\Shelley\RAI\chapters\CHAPTER SCHEME1 andPOA-7.doc

6.3.2 Induced abortions (IA) (reported induced abortions form the denominator): IA in lifetime
including those in the reference period and IA s only in reference period
• Birth order
• Sex composition of the children at die birth order
• Reasons for seeking abortion
• Use of contraceptives

•

Length of gestation at die time of abortion

Decision makers
Cross tabulation and multivariate analysis:
• Variation across urban/mral will be examined for all of the above variables.
• Reasons for abortion by caste/religion,
• Reasons for abortion by birth order in rural and urban (tliree way)
• Reasons by sex composition of children in rural/urban (three way)
• Reasons by length of gestation in rural/urban (reasons)
• Reasons by time (single years/year classified - analysis of the reasons across the time) in
rural and urban
• Reasons - life time and reference period - to see if there is change in the pattern (time series
analysis?)
• Reasons by practice of contraceptive

6.3.3 Comparison of women with at least one pregnancy but with no single experience of induced
abortion with the women with at least one experience of induced abortion, (all women
research participants would form the denominator)
On parameters
• Socio-economic
• Standard of living index
• Place of residence: Rural/urban
• Tribal/non-tribal
• Use of contraceptives
6.3.4

Spontaneous abortion (Reported spontaneous abortions form the denominator)
• Birth order
• Perceived reason/s for abortion
• Length of gestation

6.3.5

Still births (Reported still births form the denominator)
• Birth order
• Perceived reason for abortion
• Length of gestation (more than 7 months)

34

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S

NATIONAL DIALOGUE ON CHALLENGES OF SEX SELECTIVE ABORTION

Jan Swasthya Abhiyan
The 2001 Census highlighted the drastic decline in child sex ratios in several states in

North and West India and continued declines in major Southern states. The above dialogue was
held in Rohtak, Harayana on 14,15 April 2001. Jan Swasthya Abhiyan organised the event. This
Abhiyan is an outcome of the People’s Health Assembly (PHA) held in Calcutta in November

2000. PHA was a collective effort of 18 major networks of organisations in the country.

Over 40 delegates from 8 states came for this dialogue. Women’s organisations,
researchers, medical professionals, trade unionists, media representatives and NGOs participated

in the deliberations. Participants included Dr. Mira Shiva (Voluntary Health Association of

India), Dr. Ranbir Singh Dahiya, (Professor Rohtak Medical College), Dr. Amit Sen Gupta (All
India People Science Network), Mr. M. Jeeva (TamilNadu Campaign against Sex Selective

Abortion), Dr. K. Biswas (West Bengal Vigyan Manch) Dr. Sabu George (Community Health
Cell, Bangalore), Ms. Sudha Sundaraman (All India Democratic Women’s Association), Ms. K.

Kalpana (Tamil Nadu Science Forum), Ms. Archana Kaul (SCOPE, Jammu & Kashmir) Ms. R.
Kaur (National Federation of Indian Women), Ms. Savita (All India Women’s Conference) and
Dr. Dinesh Khosla (Kids’ Careclinic, Rohtak & Indian Academy of Pediatrics).

Specific recommendations for legislative, administrative and professional action were
finalised. The policy statement and the demands to the Government are enclosed. The

participating organisations committed to launch public campaigns against this heinous crime. The
campaign will sensitise the medical professionals and make efforts to involve the ethical

practitioners. Further, we will reach out to the Government health workers, Anganwadi workers,
Panchayat representatives, teachers and trade unions. The campaigns will first be initiated in the

states of Haryana, Delhi, UP and Himachal. The ongoing campaign against sex selective abortion
in TamilNadu will be strengthened and extended over the next 6 months to the adjacent statesKarnataka and Andhra.
We deeply regret to note that none of the invited Government officials of the Health
Departments from the states of Haryana, Punjab, Delhi participated. Despite the strenous efforts

of the organisers, the senior functionaries of the Union Health & Family Welfare Ministry did not
attend We were disappointed that not even the National Appropriate Authority of the PNDT Act
chose to send a representative to this meeting.
Contact Person-Professor R. S. Dahiya
National Convener of the Dialogue & Haryana Gyan Vigyan Samithi
19/8 FM, Medical College Enclave, Rohtak, 124001.
Phone-01262-51231 (Residence); 01262-44916 (Office); email-dahiyars@redifffnail.com

kJ H’J

April 15, 2001
POLICY STATEMENT ON SEX SELECTIVE ABORTION (Female feticide)

The 2001 Census reveals that there has been a dramatic drop in child sex ratios (0 to 6
year olds) in the states of Punjab, Haryana, Himachal, Delhi, Gujarat, Chandigarh and

Maharastra as compared to the 1991 Census. Punjab has an alarming ratio of 793 girls per
thousand boys. These were the states where the private fetal sex determination clinics were

first established and the practice of selective abortion of female fetuses became popular in the
late seventies and early eighties. Even the Southern states such as Karnataka, TamilNadu and

Andhra have shown decline in child sex ratios. The drops in this Census are less than the
Northern states as the sex determination clinics emerged in the South only a decade after they

became popular in the North. The emergence and spread of the prenatal sex determination

clinics are the early warning signals for the distortion of sex ratios at birth in the coming
decade following selective elimination of girl fetuses.
People’s Health Assembly (PHA) held in Calcutta in November 2000 was a collective

effort of 18 major networks of organisations in the country. Jan Swasthya Abhiyan which has

been launched following the PHA organised a dialogue on the challenges of sex selective
abortion (female feticide) at Rohtak, Haryana on April 14-15, 2001. Delegates of 8 states

right from Jammu & Kashmir to TamilNadu were involved. Women’s organisations,
researchers, medical professionals, trade unionists, media representatives and NGOs

participated in the deliberations. Specific recommendations for legislative, administrative and
professional action were finalised. This event is significant in that it involved participants who

have been warning the government and the public for nearly a decade about this impending
disaster. They have been highlighting the lack of ethics in the medical profession and the
almost complete lack of enforcement of the 1994 national law against prenatal sex

determination by the Union and State Governments.
Various functionaries of the Government of India and the State governments should be
seized of the enormity of this form of gender violence. The drop in child sex ratios is a

reflection of the worsening status of women in our country. Regrettably, the 1994 Prenatal

diagnostic technologies act (prevention and regulation of misuse) has not been implemented in
these states. For instance, the National Advisory Committee has not been meeting every six
months as mandated by the Act and the Appropriate Authorities in almost all the Districts have

not constituted by the states as of June 2000. The National Appropriate Authority had not
taken effective steps for even registration of all ultrasound machines.

We consider prenatal sex determination tests as a basic human rights violation and a

violation of the rights enshrined in the Constitution, the United Nation Convention on the

rights of the child (CRC) and the Convention on the elimination of all forms of discrimination
against women (CEDAW). Female feticide must be seen as one manifestation of gender

violence against women. Further, efforts to aggressively implement various acts such as
Medical Termination of Pregnancy Act, Dowry Act etc., which protect women’s rights must

also be taken up. Our campaign against prenatal sex determination is not part of the campaign
against abortion. The right to abortion is an essential right of women.
While population policy documents in the country may not be explicitly promoting sex

determination, but in actual reality a significant part of the decline in growth rates is caused by

selective elimination of girl fetuses in parts of the country where female feticide has received
widespread legitimacy. Even United Nations Fund for Population Activities (UNFPA) has
acknowledged this finally. We advocate that the Government’s family welfare policies and

programmes should endeavour to attain a demographic transition to lower fertility rates with
gender equity. Otherwise, the current emphasis solely on population stabilisation would lead
to serious decline in child sex ratios in other parts of the country also, which will cause

irreparable psychological and physical trauma to generations of surviving women.

DEMANDS TO THE GOVERNMENTS

Given the enormity of sex selective abortion, the participants demand that:1.

The Government of India should effectively implement the 1994 PNDT Act. The
Appropriate Authority of the Act should urgently take steps to notify the State
Governments to register all Ultrasound machines as today ultrasound has become the

most common technology being abused for sex determination. The State Governments

of TamilNadu, Kerala and Karnataka have recently initiated registration of these
machines.
2.

The Government should file criminal cases immediately against medical professionals,
scan operators and clinic owners who violate the PNDT Act. Particularly, those who
advertise prenatal sex determination should be identified and prosecuted. Regulatory
authorities such as Medical Council of India (MCI) should take action against the

erring Doctors.
3.

The Government should urge professional medical associations such as the Indian
Medical Association (IMA) and other specialist medical organisations to get their

members to register their ultrasound machines and monitor their use. Regrettably,
even prominent IMA members such as national office bearers and even the Delhi
Health Minister have not taken the lead in getting ultrasound machines registered.
4.

The Government should vigorously publicise the PNDT Act, highlight the value of the
girl child and sensitise the society about the inevitable increase in violence against

surviving girls,/women in the decades to come.The National Population Commission
should immediately convene a special session to discuss the decline in child sex ratio.

The National population policy should explicitly state that population stabilisation
should be attained without distortions in sex ratio at birth.
5.

All Government programmes for the welfare of the girl child and women should be

implemented vigorously to reduce and eliminate gender biases. The longstanding
demands of women’s organisations of equal wages for women, property rights and

social security measures should be immediately enforced
6

The National Commission for Women should be directly involved in the

implementation of the PNDT Act. Therefore, the existing Act be amended so that the

NCW appointees becomes the Co-Appropriate Authorities at the Union and State
levels. Note the original Maharastra Act of 1988 had a multi-member group as the

Appropriate Authority.

I

PRE-NATAL DIAGNOSTIC TECHNIQUES

(Regulation and Prevention of Misuse)
ACT, 1994

Advocating Effective Medical Compliance
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MEDIA ADVOCACY
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What Can We Achieve?
GENERATE PUBLIC DEBATE
INCREASE MEDIA COVERAGE
PROMOTE GENDER-SENSITIVE PERSPECTIVE

INFLUENCE PUBLIC OPINION
INFLUENCE PUBLIC POLICY
ENSURE ADHERENCE TO THE LAW

EXAMPLE:

Curb the Growing Practice of Foeticide,

Ensure Effective Adherence to the Law

on Pre-natal Diagnostic Techniques
(Regulation and Prevention of Misuse) Act, 1994

GOAL:
To bring out medical, ethical guidelines,

to prevent the diagnostic practice of sex selection.

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MESSAGE
Private clinics equipped with sophisticated facilities to detect sex of

foetus are directly responsible for the growing unlawful practice of

foeticide.
Change the mindset of Doctors.

DEBATE
First time leading
Medical Associations and

Regulatory Bodies encouraged by
international agencies like UNICEF

come together to denounce
the medical malpractice of
conducting foeticide in collusion

with interested clients.

A National workshop on
female foeticide and infanticide

in Delhi saw
TWO PILLARS of the
Medical establishments in India -

the Medical Council of India (MCI) and
the Indian Medical Association (IMA) come together on the issue and

jointly vow to fight the crime.
Indian Express, 28 September 1999

MEDIA COVERAGE ACCOMPLISHED THE FOLLOWING
^^ained visibility for IMA, MCI
Were seen as spearheading the opposition to the practice.

Took ownership of the problem.

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Get the active and positive support of the media and civil society.

gustained coverage

IMA is collaborating with the Medical Council of India for a law to de-recognise

all medical practitioners who are found conducting sex determination tests like
amniocentesis.
The Hindu, 28 July 1999

Doctor's mindset should be changed to prevent them from misusing the
techniques to illegally determine the sex of a foetus
Free Press Journal, 28 July 1999

IMA is thinking of taking up the role as complainant.
Statesman, 6 August 1999

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With this campaign we are fighting against some within our own fraternity.
Indian Express, 28 September 1999

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IMA has decided to back its rhetoric with action, by appealing to doctors on

the issue, warning them that sex selection and selective abortion is a violation

of the Pre-natal Diagnostic Techniques Act 1994.
/Vews Times, 7 December 1999

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Why Women are Lesser in India
The Pioneer, 13 July 1999, Delhi

India Murders its Women
The Hindustan Times, 22 August 1999, Delhi

Where have all the Girls gone?
Telegraph, 10 November 1999, Calcutta

Waging war against Killer of unborn girls
The Tribune, 10 November 1999, Chandigarh

Bhurn Katya keliye Kendra Sarkar zaroori kadam uthayegi
Nai Duniya, 30 January 2000, Indore

Implementation of Pre-Natal Diagnostic Techniques Act sought
Hindu, 17 May2000, Madras

OUTCOME

IMA Succeeded in Becoming

One of the Key Spokesperson
on Child Rights

KEY ELEMENTS IN MEDIA ADVOCACY
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Setting the agenda - Making it Newsworthy

Shaping the Debate - Positioning it
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A two-day workshop is being
jointly organised by

UNICEF and the women's wing of IMA
to focus on...issues related to foeticide.
Free Press Journal 28 July 1999

The workshop will come up with...
guidelines to prevent the practice.
Free Press Journal, 28 July 1999

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Unanimous in their condemnation
of the increasing incidence of
female foeticide were

Delhi's Health Minister Dr. A.K.Walia;
Dr. Ketan Desai, President, MCI;

Dr. V.C.Patel, President, IMA and

Dr. Prem Aggarwal, President, IMA.
The Indian Express, 8 August 1999

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PLANNING FOR THE MEDIA ADVOCACY
EXAMPLE

ISSUE

Curbing the Misuse of
Pre-Natal Diagnostic Techniques

for Sex Determination

HOW TO STRENGTHEN THE ISSUE

Project a Professional Commitment to campaign against the practice

The workshop will be attended by participants from the Health Ministry,
National Commission on Women, Ministry of Women and Child Development,
UNICEF, WHO, and state branches of IMA.
Free Press Journal, 2&h July 1999

SOLUTIONS

Empower the regulatory authorities
to take action against
medical practices
The Medical Council of India
has warned stripping the registration
of any doctor found at default.
Statesman, 6 August 1999

Develop amendments in law
that will address weakness
in the present bill

The Centre for Child and Law of the
National Law School, Bangalore,
has recommended that female foeticide and
the burden to disprove it should rest
on the father and other relatives.
The mother should be innocent till proved guilty.
The Hindustan Times, 22 August 1999

Medical, ethical guidelines in
collaboration with legal institutions

IMA had a meeting at the
Bangalore Law School on
medical-legal issues of female foeticide.
News Times, 7 December 1999

ISSUE LINKED WITH

> Adverse sex ratio
The 1991 census shows that the ratio of women to men in Delhi has gone
down to 887:1000 as against 943:1000 in 1901
Times Of India, 13 October 1999

> Public rally to draw attention
A rally against the menace of female foeticide was organised at India Gate
Times of India, 18 November 1999

VOICES
MEDICAL BODIES AND ASSOCIATIONS

Female foeticide widespread: IMA
Free Press Journal, 28 July 1999

INTERNATIONAL AGENCIES

My organisation would align itself with all attempts to achieve a better deal for
the girl child
Ms Geeta Athreya, UNICEF
The Pioneer, 8 August 1999

POLITICAL LEADERS

Strict action, including imprisonment, will be taken against anyone indulging in
and abetting female foeticide and infanticide
Delhi Health Minister, Dr.A.K. Walia
Pioneer, 8 August 1999

EXPERTS

We are not fighting against abortions but only against the crude practice of
female foeticide
Dr Ashish Bose, Honorary Professor, Institute of Economic Growth, Delhi
Pioneer, 9 August 1999

OFFICIALS

It is high time that the killing of female foetus is checked
Mr. Vishnu Bhagwan, Principal Secretary to the Haryana Chief Minister
Hindu, 10 October 1999

SOCIAL ACTIVISTS

The law has not been able to enforce a single conviction. The only perceptible
change has been that blatant hoardings and advertisements on sex
determination have disappeared
Dr Mira Shiva, Voluntary Health Association of India
Telegraph, 10 November 1999

MESSAGE PROVIDED
The evil of foeticide continues to proliferate with the mushrooming of
private clinics with sophisticated ultrasound and amniocentesis
facilities.

Statesman, 6 August 1999

The Indian Medical Association is planning to take up the role as a
complainant in cases of murders in the womb
Statesman, 6 August 1999

Of 8,000 aborted foetuses, only one was a male: Survey
Indian Express, 8 August 1999

MCI will ensure that doctors guilty of female foeticide are not allowed
to practise.
The Times of India, 13 August 1999

Physician, heal thyself before its too late
Indian Express, 28 September 1999

The Indian Medical Association and the Medical Council of India are
gunning for the foetal sex determination industry
Indian Express, 28 September 1999

The IMA will organise a rally against female foeticide.
The Tribune, 10 November 1999

Conducting such tests may even lead to de-recognition of the medical
degree
Times of India, 18 November 1999

IMPLEMENTING MEDIA ADVOCACY ACTIVITIES
Issue:

To improve the medical adherence to the Act
To target medical practitioners
Was the policy message clear?
Who was targetted?

Practitioners - guilty ones

Yes

Who were the spokespersons?
Dr Prem Aggarwal, IMA
☆ Ms Geeta Athreya, UNICEF
Dr Sharda Jain, IMA women's wing

Mr. Ketan Desai, MCI
Dr A.K.Walia, Delhi's Health Minister

Compelling numbers

Yes

In Certain Communities in Bihar and Rajasthan, the sex ratio has plummeted
to 600 females per thousand
Free Press Journal, 28 July 1999

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What worked?

❖ Cohesive voice
❖ Strong message
❖ Brought on boarddiverse groups

What is missing?

Final inability to expose even one guilty practitioner.
By May 2000 loosing media attention to other groups.
Media
RF_WH_8_PART_2_SUDHA.pdf

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