Female Foeticide: Medico-legal Issues

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Presentation contains brief about female foeticide including salient features of the PCPNDT Act & MTP Act.

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“Female Foeticide: Medico legal Issues” :

“ Female Foeticide: Medico legal Issues ” Dr. P. C. Srivastava Professor Dept. of Forensic Medicine RMCH, Bareilly

Slide 2:

50 million girls and women “going missing” from India’s population (due to gender discrimination) – United Nations Children’s Fund .

Ten million missing girls in 20 years in India !!:

Ten million missing girls in 20 years in India !!

Slide 4:

The world population has a sex ratio of 990 females Sex ratio: Japan 1041 USA 1029 Indonesia 1004 Bangladesh 953 China 944 India 940 India has one of the lowest sex ratios in the world WikiProject India Maps

Slide 6:

In some villages of Madhya Pradesh, no marriages have taken place for years because there are no girls and the boys are married by buying girls from far away villages of neighbour states.

The 200 Rathore families in a Rajput-dominated village in Western Rajasthan’s Barmer district have on average 2 to 4 male children/family. Only 2 girls are in the village. The ratio is 400 male children : 2 female children.:

The 200 Rathore families in a Rajput-dominated village in Western Rajasthan’s Barmer district have on average 2 to 4 male children/family. Only 2 girls are in the village. The ratio is 400 male children : 2 female children.

Devra village of Jaisalmer district has the distinction of receiving a baraat after 110 years in 1997, when Jaswant Kanwar got married. Woman in the centre is the mother of Jaswant Kanwar:

Devra village of Jaisalmer district has the distinction of receiving a baraat after 110 years in 1997, when Jaswant Kanwar got married. Woman in the centre is the mother of Jaswant Kanwar

In Dang district, Gujarat-Rajasthan border, 8 brothers of the same family are married to Sarup in the centre. Getting a wife is extremely difficult in this region. Sept. 2001, India Today:

In Dang district , Gujarat-Rajasthan border, 8 brothers of the same family are married to Sarup in the centre. Getting a wife is extremely difficult in this region. Sept . 2001, India Today

Ancient status Vs. Current status:

Ancient status Vs. Current status “Yatra Naryastu pujyante, ramante tatra Devata” (Manusmriti 3.62) “Women are honoured where, Divinity blossoms there ” Female was well respected, was celebrated as the font of creation and as an equal half of her husband.

Contd…:

Contd… P reference for sons has been prevalent in Indian households from time immemorial , even then Vedic society gave prominence to female supremacy . Slowly patriarchal customs, rituals and beliefs changed our mind for secondary status to the women in the society. A newly-wed bride is usually blessed to “be a mother of 100 sons”. When a woman become pregnant, other women in the family chant mantras exhorting the female foetus to be transform into a male foetus.

Contd…..:

Contd….. Marriage: the burden of the father passed on to the husband for a very high price. Violence against females like: domestic violence, rape , sexual abuse, dowry harassment, trafficking , female foeticide, etc . is responsible for low preference of a female child.

Why Female Foeticide?:

Why Female Foeticide? R arely any one prefers to have more children because of social burdens. For continuance of ones property, and gene, the need of a heir; a son becomes necessary. Amniocentesis and sonography - widely available to determine the sex. Termination of pregnancy - simple and accessible. Female foeticide - quite easy as compared to female infanticide. Couple adopts evil “It is better to spend Rs. 500 now than Rs. 5,00,000/- (in dowry) later.” L ittle mechanisms to combat the female foeticide either by way of effective laws and implementation or civil society action. As A CONSEQUENCE….. The birth of a girl child in a family avoided FEMALE FOETICIDE

Slide 14:

In India, female infanticide has been practiced for centuries with the earliest evidence being provided by Sir Jonathan Duncan in 1789. (Ref.: Pakrasi KB, Haldar A. Sex ratios and sex sequences of births in India. J Biosoc Sci 1971;3:327-37).

Slide 15:

Nationwide registered cases of Infanticide & female foeticide (Source: NCRB) Year No. of Infanticide cases No. of female foeticide cases 2009 63 123 2010 100 111 2011 63 132

Why female foeticide > infanticide?:

Why female foeticide > infanticide? The moral guilt of female foeticide < female infanticide. Mushrooming of sex determination and abortion centres in all parts of the country including small districts and villages. Unethical practices by some of the Medical practitioners for sex determination & female foeticide. Many centres are manned not by qualified doctors but by only technicians.

Legal Provisions :

Legal Provisions 1. The IPC, 1860 2. The MTP Act, 1971 3. The PNDT Act, 1994

Offences related to miscarriage under the IPC :

Offences related to miscarriage under the IPC Section Offences Punishment S. 312 IPC Causing miscarriage Imprisonment up to 3 years, or with fine or with both if the woman be quick with child Imprisonment may extend to 7 years, and fine . S. 313 IPC Causing miscarriage without woman's consent imprisonment for life or with imprisonment which may extend to ten years + fine

Slide 19:

S. 315 IPC Act done with intent to prevent child being born alive or to cause it to die after birth Imprisonment for a term which may extend to ten years, with/without fine S. 316 IPC Causing death of quick unborn child by act amounting to culpable homicide Imprisonment for a term which may extend to ten years + fine

The PNDT Act, 1994:

The PNDT Act, 1994 With the rise of pre-natal diagnostic techniques especially amniocentesis (1975), the government in 1978 issued a directive banning the misuse of amniocentesis in government hospitals/laboratories . A law to prevent misuse of sex determination tests was passed in Maharashtra known as Maharashtra Regulation of Pre-natal Diagnostic Techniques Act, 1988 . Finally the Parliament enacted the Pre-Natal Diagnostic Techniques (Regulation and Prevention of Misuse) Act on 20th September 1994.

The Pre-conception and Pre-natal Diagnostic Techniques (Prohibition of Sex Selection) Act 2003:

The Pre-conception and Pre-natal Diagnostic Techniques (Prohibition of Sex Selection) Act 2003

The Pre-conception and Pre-natal Diagnostic Techniques (Prohibition of Sex Selection) Act 2003 :

The Pre-conception and Pre-natal Diagnostic Techniques (Prohibition of Sex Selection) Act 2003 Provides for the prohibition of sex selection, before or after conception. Regulates the use of prenatal diagnostic techniques , like ultrasound and amniocentesis by allowing their use only to detect: → genetic disorders → metabolic disorders → chromosomal abnormalities → congenital anomalies → haemoglobinopathies → sex-linked diseases

Slide 23:

PNDT can be conducted only by clinics & persons registered under the Act. Salient Features of t he PCPNDT Act Use of PNDT allowed only on medical grounds & not for determination of sex. P erson conducting prenatal diagnostic procedure shall not disclose the sex of the foetus to pregnant women or her relatives.

Contd… :

Contd… Declaration of pregnant woman that she does not want to know sex of the foetus Declaration on each report that he/she (doctor) has neither detected nor disclosed the sex of foetus to pregnant woman or to any body Clinics involved in advertisement (conducting sex determination) are liable for punishment Clients and their relatives asking for sex determination are also punishable . Offences under PNDT Act are cognizable, non-bailable and non-compoundable .

It is mandatory for everybody registered under this Act to: :

It is mandatory for everybody registered under this Act to: display the certificate of registration at a conspicuous place in such centre, laboratory or clinic. 2. display prominently a notice that “ they do not conduct any technique, test or procedure, etc. for detection of sex of foetus or for selection of sex before or after conception”.

Maintenance of records by USG centers :

Maintenance of records by USG centers Declaration of pregnant woman that she does not want to know sex of the foetus. Declaration by doctor on each report that he/she has neither detected nor disclosed the sex of foetus. Report to be sent by 5th of every month to appropriate authority. Records to be made available to appropriate authority for inspection . All records to be preserved for two years or till disposal if the case is pending in the Court .

Declaration of pregnant woman that she does not want to know sex of the foetus:

Declaration of pregnant woman that she does not want to know sex of the foetus I , Ms.______________________(name of the pregnant woman) declare that by undergoing ultrasonography/image scanning etc. I do not want to know the sex of my foetus . Signature/Thumb impression of pregnant woman

Declaration of doctor/person conducting ultrasonography/image scanning:

D eclaration of doctor/person conducting ultrasonography/image scanning I, _________________________________ (name of the person conducting ultrasonography/image scanning) declare that while conducting ultrasonography/image scanning on Ms .___________ (name of the pregnant woman), I have neither detected nor disclosed the sex of her foetus to any body in any manner. Name and signature of the person conducting ultrasonography/image scanning/Director or owner of genetic clinic/ultrasound clinic/imaging center.

Advantages of maintenance and preservation of records:

Advantages of maintenance and preservation of records Helps to prove that their action was in accordance with the law and the rules in case of any c omplain against the center or clinic or laboratory . Non-maintenance of proper records: i). can itself give rise to a cause of action ii). indicative that the center is conducting pre-natal diagnostic techniques for the purpose of determination of the sex of the foetus or in violation of the Act .

Sex selection:

Sex selection Includes: • Procedure • Technique • Test • Administration • Prescription • Provision of anything for the purpose of ensuring or increasing the probability that an embryo will be of a particular sex .

Preconception Sex Selection:

Preconception Sex Selection 1 . Chinese Birth Chart : Believed to be t housands of years old and is based on the Chinese Lunar Calendar. Ancient Chinese Pregnancy Calendar used: i). To predict the gender of an unborn baby . ii). As a pre-conception gender selection tool .

Preconception Sex Selection:

Preconception Sex Selection 2. Gradient Method: Sperm from the father is centrifuged to separate sperm with Y-chromosomes from X-chromosomes (heavier due to more genetic material). Sperm with the desired chromosome is then used in IUI in order to produce a child of the desired sex.

Preconception Sex Selection:

Preconception Sex Selection 3. Flow Cytometry : Indicated in known or suspected risk of sex-linked (X-linked) genetic disorders It uses fluorescent dye to highlight sperm that carry X chromosomes. X-bearing sperm (contains more genetic material) pick up more dye than the Y-bearing sperm . Two types of sperm are then separated by a laser machine  sperm with appropriate chromosomes then used in IUI/IVF .

Pre-implantation Genetic Diagnosis (PGD) :

Pre-implantation Genetic Diagnosis (PGD) PGD is one of the most successful methods for gender selection. Embryos created in a laboratory ------> allowed to divide. After three or four days, cell from embryo is removed ------> analyzed for DNA and genetic material. The sex of the embryo determined  embryo of the desired sex implanted into the mother’s uterus through IVF. 99 % chance of having a child of the desired gender.

“Undertaking” during Registration:

“Undertaking” during Registration Every application accompanied by an Affidavit containing an undertaking: ( i)That the Genetic Centre/Laboratory/Clinic / Ultrasound Clinic/Imaging Centre/combination shall not: conduct any test or procedure for selection of sex before or after conception or detect sex of foetus except for diseases specified in Section 4(2) Disclose the sex of foetus to any body ; and (ii) T hat the Genetic Centre/Laboratory/Clinic/combination, shall display prominently a notice that they do not conduct any technique, test or procedure, etc. for : detection of sex of foetus; or selection of sex before or after conception .

False Affidavit :

False Affidavit Offence: The making of a false affidavit is giving false evidence within Section 191 IPC. Punishment: S. 193 IPC. Imprisonment for 7 years and fine.

Prohibitions on Places:

Prohibitions o n Places The Registration certificate has to be displayed prominently in such place . Pre-natal diagnostic technique shall not be conducted by person at any place other than the place registered. Registration of persons , place and equipment is mandatory . ?? USG at Home or in Health Camps even on voluntary/charitable basis??

Prohibition on sex disclosure:

Prohibition on sex disclosure No person including the person conducting a pre-natal diagnostic procedures shall communicate the sex of the foetus by words, signs or in any other manner to the pregnant woman/her relatives/any other person.

Slide 39:

Avoid : Indirect communication : “It is time to celebrate, give me a packet of sweets”. “Oh ! your shoulders have become heavy now”. Misrepresentation and fraud : “ You see I have all the latest techniques from America , I can tell the sex of the child within 10 weeks of pregnancy” Signs and gestures : “To raise left eyebrow when it is a boy and right eyebrow when it is a girl”.

List of indications for ultrasound during pregnancy (Central Supervisory Board):

List of indications for ultrasound during pregnancy (Central Supervisory Board) To diagnose intra-uterine and/or ectopic pregnancy and confirm viability . 2. Estimation of gestational age (dating). 3. Detection of number of foetuses and their chorionicity. 4. Suspected pregnancy with IUCD in-situ or suspected pregnancy following contraceptive failure/MTP failure. 5. Vaginal bleeding / leaking. 6. Follow-up of cases of abortion. 7. Assessment of cervical canal and diameter of internal os. 8. Discrepancy between uterine size and period of amenorrhoea .

Slide 41:

09 . Any suspected adenexal or uterine pathology / abnormality. 10. Detection of chromosomal abnormalities, foetal structural defects and other abnormalities and their follow-up. 11 . To evaluate foetal presentation and position. 12. Assessment of liquor amnii. 13. Preterm labour / preterm premature rupture of membranes. 14. Evaluation of placental position, thickness, grading and abnormalities (placenta praevia, retroplacental haemorrhage, abnormal adherence etc.). 15. Evaluation of umbilical cord – presentation, insertion, nuchal encirclement , number of vessels and presence of true knot .

Slide 42:

16. Evaluation of previous Caesarean Section scars. 17. Evaluation of foetal growth parameters, foetal weight and foetal well being . 18 . Colour flow mapping and duplex Doppler studies. 19. Ultrasound guided procedures such as medical termination of pregnancy, external cephalic version etc. and their follow-up . 20. Adjunct to diagnostic and therapeutic invasive interventions such as chorionic villus sampling (CVS), amniocenteses , foetal blood sampling, foetal skin biopsy, amnio-infusion , intrauterine infusion , placement of shunts, etc. 21 . Observation of intra-partum events. 22. Medical/surgical conditions complicating pregnancy. 23. Research/scientific studies in recognised institutions.

Offences & Penalties Under the PCPNDT Act:

Offences & Penalties Under the PCPNDT Act Offences Penalties 1. If any person acts contrary to the prohibitions listed in the PNDT Act including related to advertisement • Imprisonment which may extend to 3 years; and • Fine which may extend to Rs.10,000/- Any subsequent conviction • Imprisonment which may extend to 5 years; and • Fine which may extend to Rs.50,000/-

Slide 44:

II. In case of a person seeking the aid of the bodies or persons for sex selection or for conducting pre-natal diagnostic techniques on any pregnant woman for the purposes other than those specified in Section 4(2 ), • imprisonment which may extend to three years; and • fine which may extend to Rs.50,000/-. Any subsequent conviction • imprisonment which may extend to 5 years; and • fine which may extend to Rs.1 lakh

III. In case of a registered medical practitioner:

III. In case of a registered medical practitioner His name shall be reported by the Appropriate Authority to the State Medical Council for taking necessary action: - Including suspension of the registration if charges are framed by the court and till the case is disposed of; and For the removal of his name from the register of the council on conviction for the period of: • five years for the first offence; • permanently for the subsequent offence.

Slide 46:

IV. Husband and relatives of the pregnant woman compelling the woman to undergo the pre-natal diagnostic technique • liable for abetment of offence under Section 23 (3); and • punishable for the offence under Section 23 (3).

Slide 47:

If any person contravenes any provision of the Act or the Rules for which no penalty has been specified • imprisonment which may extend to three months; or • fine which may extend to Rs.1000/-; or with both Any subsequent contravention An additional fine which may extend to Rs.500/- for every day during which such contravention continues after the first conviction.

The PNDT Act & The MTP Act:

The PNDT Act & The MTP Act T he PNDT Act has an important link with the MTP Act, 1971 Abortion is provided only in case of certain pregnancies. Under the Act, termination of pregnancy: up to 20 weeks .

Indications for termination of pregnancy under the MTP Act:

Indications for termination of pregnancy under the MTP Act i). Therapeutic : Risk to the life of the pregnant woman, or Grave injury to her physical or mental health ii ). Eugenic : Substantial risk of physical or mental abnormalities if the child were born. i ii). Humanitarian: Pregnancy is due to rape. iv ). Social grounds: Failure of methods of family planning.

Admission Register for M.T.P.:

Admission Register for M.T.P.

Entries in registers maintained in Hospital/approved places:

Entries in registers maintained in Hospital/approved places No entry indicating the name of the pregnant woman shall be made in: Case sheet OT register Follow up card Any other document or Any other register other than the Admission Register. “Reference to the pregnant woman shall be made therein by the serial number assigned to the woman in the admission register ”. (MTP Regulations, 2003)

Consent Form for Termination of Pregnancy:

Consent Form for Termination of Pregnancy

Consent for MTP:

Consent for MTP Under the MTP Act, the pregnancy cannot be terminated except with the consent of the pregnant woman . If woman’s age <18 years or she is >18 years + mentally ill: the consent of the guardian is to be taken.

Opinion Certification & Intimation of Termination of Pregnancy:

Opinion Certification & Intimation of Termination of Pregnancy

Forms to be Kept in Envelope:

Forms to be Kept i n Envelope Consent given by a woman for termination of pregnancy (MTP Rules,2003)– FORM C Certified opinion recorded under provision of MTP Regulations, 2003 – FORM I Intimation of termination of pregnancy – FORM I. NOTE : The envelope is sealed, labeled by the registered medical practitioner & sent to the head of the hospital .

Labeling of Envelope:

Labeling of Envelope The envelope is marked “secret” Serial number assigned to the pregnant woman in the Admission Register The date on which the pregnancy was terminated Name & address of the registered medical practitioner by whom the pregnancy was terminated.

Monthly Statement to be Sent to C.M.O.:

Monthly Statement to be Sent to C.M.O .

Slide 58:

The sex of the foetus can be known only after the 14th week through ultrasonography, In second trimester abortion the doctor should be vigilant regarding female foeticide.

Offences & Penalties under the MTP Act:

Offences & Penalties under the MTP Act Offences Penalty Termination of pregnancy by a person who is not a RMP (as per the MTP Act) Rigorous imprisonment for 2 – 7 yrs. Termination of pregnancy by a person in a place other than Govt. hospital or Approved hospital by the authority (CMO) Rigorous imprisonment for 2 – 7 yrs. Person being owner of the place which is not approved for MTP and where termination of pregnancy is performed Rigorous imprisonment for 2 – 7 yrs.

Slide 60:

But if the termination of the pregnancy is necessary to save the life of the pregnant women, it can be terminated validly by RMP irrespective of: the length of the pregnancy and the opinion of two registered medical practitioners.

Slide 61:

Protection of action taken in good faith : – 1. A RMP shall not be guilty of any offence under the IPC/any other law, if the pregnancy is terminated by him in accordance with the provisions of the MTP Act. 2. Under this MTP Act, no suit or legal proceedings shall lie against any registered medical practitioner for any damage caused or likely to be caused by anything, which is done or intended to be done in good faith.

Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations 2002 (7.6 Sex Determination Tests):

Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations 2002 ( 7.6 Sex Determination Tests) Any act of termination of pregnancy of normal female foetus amounting to female foeticide: Penal erasure + Criminal proceedings as per the provisions of the MTP Act .

DECLARATION:

DECLARATION At the time of registration, each applicant shall be given a copy of the following declaration by the Registrar concerned and the applicant shall read and agree to abide by the same: 1) I solemnly pledge myself to consecrate my life to service of humanity. 2) Even under threat, I will not use my medical knowledge contrary to the laws of Humanity . 3) I will maintain the utmost respect for human life from the time of conception. 4 ) I will not permit considerations of religion, nationality, race, party politics or social standing to intervene between my duty and my patient. 5) I will practise my profession with conscience and dignity. 6) The health of my patient will be my first consideration. 7) I will respect the secrets which are confined in me. 8) I will give to my teachers the respect and gratitude which is their due. 9) I will maintain by all means in my power, the honour and noble traditions of medical profession. 10 ) I will treat my colleagues with all respect and dignity. 11) I shall abide by the code of medical ethics as enunciated in the Indian Medical Council ( Professional Conduct, Etiquette and Ethics) Regulations 2001. I make these promises solemnly, freely and upon my honour. Signature ……………… Name …………………………. Place ……………….. Address ………………………. Date …………………

Slide 64:

A good doctor : (i) S hould counsel the patient that sex-determination is illegal, and (ii) Should also positively propagate about the girl child. A doctor is highly regarded in the society and any counselling by him/her will have great impact in the implementation of the Act.

How can we impact female foeticide? :

How c an w e impact female foeticide? Be vigilant towards misuse of technology and morally pressurize doctors indulging in Sex selection. Take initiatives to break silence around this issue Stop sympathizing with perpetrators Counsel vulnerable couples & link with local NGO for community support Value and celebrate the girl child’s life in your family and community Advocate to promote positive image of girl child Strictly Abide by the PCPNDT Act.

Summary:

Summary Strictly Abide by the PCPNDT Act, MTP Act & the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations 2001 .

Slide 68:

I Will be Safe in YOUR HANDS

References:

References 1. Handbook on Pre- Conception & Pre- Natal Diagnostic Techniques Act, 1994 and Rules with Amendments. 2. The Medical Termination of Pregnancy Act, 1971. 3. Garg S, Nath A. Female feticide in India: Issues and concerns . J Postgrad Med 2008;54:276-9 . 4. Crime in India 2011 Compendium. National Crime Records Bureau. Ministry of Home Affairs, Government of India, New Delhi. 5 . India's missing girls: Unholy nexus Between Tradition and medical Technology . Adv Kamayani Bali Mahabal Human Rights Lawyer and Activist, Bombay . www.brainybetty.com 6 . Stop female foeticide.avi downloaded from http://www.youtube.com/watch?v=CNYFZkb0FDk

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