India's National Magazine
From the publishers of THE HINDU

Vol. 15 :: No. 25 :: Dec. 05 - 18, 1998

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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

AT 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 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 foetus 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?

This is Usilampatti taluk in Madurai district in southern 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 campaigns 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 practised here widely.

K. GANESAN
A scan centre in Usilampatti. Such centres have proliferated in villages that otherwise have the most rudimentary public health facilities.

As I discovered during a visit to some villages in Usilampatti taluk in mid-November, many mothers seem to starve or suffocate their female children to death, making the deaths appear "natural". Women waiting outside a scan centre in Thirumangalam village spoke of one instance in Pudipuram village in which a baby girl had died within five days of birth: she had been starved to death. In Kumuli village, a 15-day-old girl had been buried alive. And in Sadachipatti village, a baby girl was left in front of a table fan running at full speed. She died within a few hours.

Increasingly, female foeticide is being widely practised in many villages in Madurai district and the neighbouring Salem district. Advances in medical technology are being misused to aid the practice: in recent years there has been a proliferation in the number of scan centres even in remote villages that otherwise have only the most rudimentary public health facilities. There are 13 scan centres in and around Usilampatti taluk - three in the town, five in Theni, two at Thirumangalam, and one each at Andipatti, Vathalagundu and Kallupatti. In Madurai city, 40 km from Usilampatti town, there are over a hundred scan centres.

All the scan centres in Usilampatti taluk operate illegally - they have not obtained certificates of registration from the appropriate authority as required under law. For Rs.150, the centres scan foetuses to determine the sex - in blatant violation of the law and medical ethics - and discreetly disclose the one bit of information that will decide whether or not the foetus will be allowed to live: its gender.

EMERGING from the scanning room, Rajathi is crying uncontrollably: it is a girl. Certain that she will not be able to face her husband and mother-in-law, she decides to go back to her parents' village and abort the foetus. Some of the women in the village will help her; their methods will be crude and will probably put Rajathi's own life at risk, but her mind, conditioned by traditional social values that look upon female children as a "burden" on the family, is made.

Amaravathi too has discovered that she bears a girl child, but unlike Rajathi, she contemplates abortion with nonchalance. "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, Lingan-ayakanpatti, 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.

SEX-DETERMINATION tests and, consequently, female foeticide became known in India in the 1970s. Amniocentesis, an invasive sex-determination test, was prevelent in the 1970s and the early 1980s in Delhi and spread rapidly to other parts of the country, particularly to Maharashtra (Frontline, July 9-22, 1988). According to some independent estimates, of the 8,000 abortions done in Maharashtra in 1987, 7,999 involved female foetuses. With public outrage against amniocentesis mounting, the Maharashtra Government enacted a law on May 10, 1988 to regulate pre-natal diagnostic centres. None of the other States or the Central Government, however, did so. It was only in 1994 that the Pre-Natal Diagnostics (Regulation and Prevention of Misuse) Act was put in place.

Under the Act, pre-natal diagnostic scans are permitted solely to detect genetic abnormalities at the pre-natal stage. The Act forbids sex-determination tests. Chapter III Section 6(b) of the Act states: "No person shall conduct... any pre-natal diagnostic techniques ... for the purpose of determining the sex of a foetus." Further, Chapter III Section 5(2) of the Act states: "No person conducting pre-natal diagnostic procedures shall communicate ... the sex of the foetus by words, signs or in any other manner."

The Tamil Nadu Government framed the rules and gazetted the Act in January 1996. Section 17(1) of the Government of India Gazette Notification states: "Every clinic shall prominently 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 pre-natal diagnostic procedure, scan centres are required 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 impunity. And sex-specific abortions, assisted in many instances by doctors and paramedical personnel, continue to be performed, sometimes at great risk to the woman. The long-term sociological consequences of these unlawful, unethical acts are serious in the extreme.

ACCORDING to Census of India data for 1991, the sex ratio (defined as the number of females per 1,000 males) for the juvenile population (0-6 age group) of Tamil Nadu was 948, against the national average of 945. However, the figures in respect of three districts in Tamil Nadu - Salem (849), Dharmapuri (905) and Madurai (918) - are revealing. Salem district, in fact, recorded the lowest 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 of 900 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 primary health centres in the State. Female infant mortality rate (defined as mortality 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 of Tamil 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. The State average was 24.

K. GANESAN
A scan centre in Madurai.

I SET out from Madurai for Usilampatti taluk along with members of the Society for Integrated Rural Development (SIRD), a voluntary organisation which has been active in the area for 20 years and which in 1986 first highlighted the instances of female infanticide in the region. They are: SIRD field director M. Vasu and field officers C. Maunam, P. Pavalam and C. Jayamani. The economy of the region is primarily agrarian, and as we approached Usilampatti town, the landscape turned from fertile to dry. The disparity in living conditions in the different areas was striking. In the fertile areas, the houses were regular constructions and had television sets, refrigerators, mixies, grinders and sofa sets. In contrast, in the dry areas, the houses were thatched structures and had few belongings.

We were to meet a few SIRD members; since most of them were apprehensive about talking to us in their villages, we had arranged to meet them at the SIRD office at Periyasemmet-tupatti, two km from Usilampatti town. By the time we reached the village, 28 women from nine surrounding villages had gathered. Initially most of them claimed that they had never committed female infanticide or foeticide. But even as they narrated instances in "other families", some of them broke down and confessed to having committed similar crimes.

Santhosam from Sadachipatti village said: "Female infanticide still goes on, but after the arrest of Karupayee the methods used are different."

Rasamma of Kalyanipatti village explained: "We no longer kill the girl baby with the poisonous sap of the oleander plant as traces of the poison can be detected (in post-mortem examinations). We make the death appear natural. For instance, we starve the baby to death or asphyxiate it... Women who cannot afford a scan or an abortion prefer these methods." Poomani of Ichampatti village said that in some instances, the baby was buried alive within the compound of the house.

Among those who go in for sex-determination scans and learn that the sex of the foetus is female, not everyone opts for or can afford an abortion in a hospital. Annakodi recalled that in Pothanpatti village a woman tried to abort her female foetus with an oleander stem. The abortion was incomplete and the woman developed high fever and fits. She was rushed to hospital but died a day later. Some women undergo abortions in their houses with the help of hospital nurses. In Vadipatti village, a six-month foetus was aborted thus in October. Early in November, a five-month foetus was said to have been aborted in Iyyamkoilpatti by a retired government hospital nurse.

A few others go to Madurai and undergo abortions at one of the dozens of private hospitals there.

SEVERAL sociological factors influence the preference for male children that is at the root of female infanticide and female foeticide. The heart-rending tale of Thedaselvam exemplifies some of them. Frail and anaemic, she had tried to abort her five-month-old foetus but her husband, who had lost both his legs in an accident, had prevented her. His overriding concern was that if she died owing to complications arising from an improper abortion, there would be no one to look after him and their eight-year-old son and six-year-old daughter: the family survives on the Rs.15 a day that Thedaselvam earns as a farm labourer. But Thedaselvam asked tearfully, "What will I do if this too is a girl? The expenditure we incur on a girl all through her life is enormous (there are six occasions on which ceremonies are to be performed for a girl). For the marriage, which entails a huge expenditure, we have to give at least 10 sovereigns of gold, a TV set, sofa, cot, cupboard, mixie and grinder. How can I afford all this?"

According to Maunam, the practice 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 family. 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 children 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 abandoned in Usilampatti. But the scheme fizzled 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 of every girl child born in poor households, was not implemented until 1997.

ACCORDING to the women of Usilampatti, following the arrest of Karupayee, fear of the law prompted a decline in the reported instances of female infanticide. It was then that scan centres mushroomed in the region, offering the facility for early detection of the sex of the foetus.

According to T.T. Guhan, Deputy Director (Administration), Directorate of Medical and Rural Health Services, Chennai, none of the scan centres in Usilampatti is registered with the Directorate, which is the Appropriate Authority for the implementation of the Act. The Advisory Comm-ittee set up to aid and advise the Appropriate Authority met on November 3; it decided to send out notices to the scan centres that have not been registered with the Appropriate Authority.

Most of the scan centres in Usilampatti have been established by doctors who appear to have little hesitation in disclosing the sex of the foetus - which they do either orally or by scribbling 'xx' (referring to the female chromosome pattern) on a piece of paper. Shockingly, doctors who run the scan centres and those who perform abortions seemed to be unaware of the Act and the fact that their actions in performing sex-determination tests and disclosing the sex of the foetus constitute a punishable violation of the law. Chapter II Section 3(3) of the Act states: "No medical geneticist, gynaecologist, paediatrician, registered medical practitioner or any other person shall... aid in conducting... any pre-natal diagnostic techniques at a place other than a place registered under this Act."

AN ultrasound scan can help determine the sex of the foetus from between 16 and 20 weeks of pregnancy depending on the parameters of the equipment. For instance, with the kinds of equipment generally available in Usilampatti, which have relatively low-resolution monitors and do not have trans-vaginal attachments, the sex can be ascertained only by around the 20th week of pregnancy. With the aid of equipment available in some scan centres in Madurai it is possible to ascertain the sex in the 16th week of pregnancy. But in Usilampatti, many doctors seem to resort to medical termination of pregnancy for their patients even between 12 and 15 weeks of pregnancy.

There is also an incidental question here of the level of reliability of ultrasound scanning, that too at a fairly early stage of pregnancy, in foetal sex determination. According to a doctor in Usilampatti, the margin of error in the case of sex determination is small. A signal from the scanning professionals almost invariably leads to an abortion regardless of the accuracy of the sex determination.

A WOMAN doctor who has been practising in Usilampatti town for 10 years said that she handled about 25 abortion cases a month - most of them incomplete abortions, pre-marital pregnancies and sex-selective abortions - after securing in each case the consent of the parents or the husband. Her clinic does not have scanning facilities but she refers her cases to centres in Madurai and Usilampatti town. Even as we were talking to her in her clinic, a man representing a scan centre in Usilampatti brought her share of Rs. 25 for every patient she referred to the centre.

She initially claimed that the sex of the foetus was never disclosed, but on repeated questioning admitted that the information was communicated orally to some women.

According to her, most of the demands for abortion came from people belonging to the Kallar community, without class distinctions. She insisted that she performed sex-specific abortions only for the poor, sometimes even six months into the pregnancy.

"Cradle babies" at Usilampatti in 1994. The "cradle baby scheme" fizzled out.

Asked if she did not consider sex-selective abortions illegal and unethical, she replied: "There is a (demand) for abortions, so I do it." She added that some nurses also performed abortions in their houses.

According to another woman doctor, private clinics performed three or four abortions a day, against the 15-20 a month performed at government hospitals. The procedure in private clinics was hassle-free and the patient would be discharged a few hours after the procedure. Before a scan was done, no forms needed to be filled in and the patient's consent was not secured because it was only an out-patient procedure, she said. This doctor too conceded that the sex of the foetus was disclosed to some patients. According to her, in several instances, the mothers had abandoned girl babies at the hospital and left within hours of the delivery; such babies were handed over to the receiving centres run by the Indian Council for Child Welfare.

A third woman doctor, who offers scan facilities in Usilampatti town, said that she performed four or five abortions a day. Asked about the ethics of sex-specific abortions, she said: "I offer the poor a place where the abortion can be conducted without health risks to the mother. Otherwise, these poor people will be at the mercy of quacks."

She claimed that there was no need for scan centres to be registered as scanning was an out-patient procedure. She admitted that she disclosed the sex of the foetus orally or symbolically or through her assistants. The number of requests for scans had increased in the last two or three years, she noted.

A private scan centre which was opened in 1996 in Usilampatti town is run by some doctors. One of them, whom we met at the centre, insisted that there was no need for the scan centre to be registered or for the pregnant woman's consent to be obtained for a scan. The centre, he said, was started as there was a demand for it in Usilampatti. He said that 75 scans a month were performed at the centre; he conceded that the sex of the foetus was disclosed orally to some women.

Another scan centre in Arasanedi, set up a few months ago, performs at least 15 scans a day. It is patronised by many people from Usilampatti taluk.

Under the Act, scan centres are required to maintain records of patients for two years. At a scan centre in Usilampatti it was claimed that records are maintained for one month and then destroyed. The doctor at the scan centre of course refused a request to let us look at the records in order to verify the broad nature of the entries.

FAILURE to implement the Act has led to the unregulated mushrooming of scan centres and the misuse of pre-natal diagnostic techniques to determine the sex of foetuses; these in turn have led to increasing instances of female foeticide, in some cases at great peril to the lives of the pregnant women.

This grim situation raises larger questions relating to basic socio-economic circumstances, pressures and 'compulsions', societal values and mental attitudestowards the girl-child, the failure of the law enforcement system to implement relevant legislation, and ethical issues concerning the medical profession.

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