The Ultrasonography Boom*

Newsletter Jan – Apr 2006

The steep decline in the sex ratio, despite the amendments in 2002 to the Pre-Conception and Pre-Natal Diagnostic Techniques (Regulation and Prevention of Misuse) (PCPNDT) Act of 1994, has jolted activists, policy makers and ordinary citizens into action. In order to study this problem and come up with an action plan, the Ministry of Health and Family Welfare, in 2004, initiated surveys in selected states to study the functioning of sonography centres, since ultrasonography was thought to be the most widely used technique for sex determination, leading to selective abortion of female foetuses. Surveys by Population Research Centres in Maharashtra, Punjab, Haryana, Karnataka, Uttar Pradesh, Gujarat, New Delhi and Andhra Pradesh, found a direct correlation between sex ratio and the number of registered ultrasound clinics.

Richer the district, poorer the sex ratio

This assumption was borne out by the stark statistics that emerged from this research. The number of registered ultrasound clinics in Maharashtra was found to be 4,345. The sex ratio in the state decreased by 29 points in 10 years (from 946 in 1991 to 917 in 2001). The report ‘A Study of Ultrasound Sonography Centres in Maharashtra’ prepared by the Population Research Centre (PRC), Gokhale Institute of Politics and Economics, Pune, revealed that the richer the people, higher was the number of sonography centres. For instance, the Western part of Maharashtra (the districts of Mumbai, Pune, Nashik, Sangli and Kolhapur) which is richer than the rest of the state, accounts for as much as 78% sonography clinics registered in the state. Thus, as is obvious from the graph below (reproduced from this study), higher the number of sonography centres, poorer is the sex ratio. The study also showed that districts with more than 100 sonography centres had a distinctly lower child sex ratio than districts with less than 100 sonography centres.

Source: Population Research centre, Gokhale Institute, Pune

Gadchiroli district with the smallest number of sonography centres (five) has the highest female sex ratio (974) in the state. Four districts -- Gadchiroli, Gondiya, Nandurbar and Bhandara -- with a fewer number of sonography centres (less than 20) have a healthier child sex ratio (958 and above).

This finding was also borne out in Karnataka. Interestingly, four districts out of 27 account for more than 70% of the ultrasonography centres. ‘Functioning of Ultrasound Sonography Centres in Karnataka’, a study conducted by the Population Research Centre at the Institute of Social and Economic Change (ISEC), Bangalore, reveals that as of December 31, 2003, there were 1,621 ultrasound sonography centres in Karnataka for which registration had been granted. Bangalore has 46% of all the centres, Belgaum and Mysore about 20% and Gulbarga about 11%. Not surprisingly, Belgaum district, which is adjacent to western Maharashtra -- where the child sex ratio is extremely low -- ranks next to Bangalore Urban district in terms of the number of sonography centres, and has the lowest sex ratio in the state.

The study from Gujarat, titled ‘A Survey of Centres Using Ultrasound Machines in the State of Gujarat’, conducted by the Population Research Centre, MS University of Baroda, revealed that there are about 1,735 registered centres/clinics using ultrasound machines in the state of Gujarat. Of these, 95% are owned by private sector. Further, 16% of registered centres appeared to have owners who are not adequately qualified, and less than half of the surveyed centres had a qualified person operating the ultrasound machine, i.e. a radiologist, gynaecologist, or a person with an MBBS or higher degree with requisite training/experience in sonography.

Lack of training and proliferation of untrained personnel is apparent from the fact that it was as late as 2002 that The International Certification and Educational Accreditation Foundation (ICEAF), was formed. The Foundation, with Dr C V Vanjani, head, department of non-invasive cardiology, Hinduja Hospital, Mumbai, as the only international member from India on the medical advisory board, aims to foster ultrasound education around the world by providing certification examination as a way to encourage an increase in the level of knowledge.

Although no clear pattern in terms of the relationship between number of sonography centres and child sex ratio emerged in the other states, it was evident that the centres were clearly not functioning according to the guidelines set out in the amended PCPNDT Act.

The studies quoted above revealed that ultrasonography is the technology that is most widely used for sex determination. The proliferation is the highest in the most prosperous states. Analysing the reasons for the widespread use of ultrasonography would enable the development of a strategic action plan.

The Economics of Social Prejudice

Increased privatisation of health care has been encouraged by the government in line with policies of liberalisation. With global revenues of an estimated $2.8 trillion, the healthcare industry is the world's largest industry. Analysts estimate that the Indian healthcare industry has the potential to show the same exponential growth as software and pharmaceutical industries in the past decade. Significantly, only 10% of the market potential is said to have been tapped till date. Liberalisation is directly reflected in the steady decrease in import duties on medical electronic equipment. This trend is depicted in the table below.

Decrease in import duties over a 7-year period (on medical electronic equipment)

Source: Big’s Easy Customs Tariff of the respective years published by the Academy of Business Studies.

Simultaneously, domestic production of ultrasound scanners has also seen a dramatic increase. The graph below shows that if we take manufacturing capacity in India in the year 1988 as 1 for each equipment mentioned here, over a period of 15 years manufacture of ultrasound scanners has gone up by 33 times whereas for other three types of medical electronic equipment the increase is only modest! Comparing these equipments is in no way meant to indicate their relative importance or utility in medical practice, the stark differences are indicative of the lopsided rise in demand for ultrasound – the only equipment out of the four that can be used for sex determination.

Disproportionate increase in the manufacture of Ultrasound scanners in India over 15 year period (1989 - 2003)

Based on Guide to Electronics Industry in India 2003, Department of Electronics, Government of India.

Liberalisation of economic policies has varying impacts on demands for various commodities. By late 80s many doctors in urban India had started advising routine ultrasonographic check-up of the developing foetus at least 2-3 times during the pregnancy. More and more people who could afford to pay for the private medical services had started opting for use of ultrasonographic scanning of the developing foetus. Naturally a demand was created for the ultrasound scanners. With the easing of import duties and increase in indigenous manufacturing capacity, the market for ultrasound scanners soared, which was reflected in a steep increase in market growth during the early nineties as has been shown in the graph below.

Source: Center for Industrial & Economic Research (CIER) and Industrial Techno-Economic Services P. Ltd (INTECOS)

The comparison here too with ECG machines is only meant to be indicative. While ECG is considered as important a diagnostic device as an ultrasound, nevertheless, the market growth rate for ECGs as compared with ultrasound scanners has varied considerably over the last decade and has always been more than that for ECG. The predicted growth rate for the ultrasound scanners in the coming decade is likely to remain higher than for ECG.

With the National Health Policy (2002) visualising “a greater role for the private sector in the urban primary care and tertiary care sectors”, and the concomitant spurt in private health insurance, it does not portend well for the health care sector in the country, which is hurtling towards a future dominated by the private healthcare industry, with profit, rather than public health, as the driving force.

These factors are undoubtedly leading to the proliferation of sex determination technologies. However, another factor, namely, sex selection, is one that is becoming more widespread, and has its own attendant issues.

Sex selection: New versus old technologies

From a shift away from amniocentesis in the 1980s when the campaign against sex determination first emerged, to the current widespread use of ultrasonography, a moot question is: Is the issue only new vs. old technologies?

A technology is developed with potential for mass use in mind, however, not all technologies prove to be equally successful. Ease of use is one major positive point which makes a technology successful. Similarly a non-invasive procedure has more public acceptance than an invasive procedure such as chorion villus biopsy or amniocentesis. As is mentioned earlier, ultrasonography machines are currently operated by many untrained people too with potential adverse consequences! However, for all practical purposes, use of ultrasound based diagnosis provides an easy to use, non-invasive technology of sex determination - the reason why other technologies lost the race while this boomed!

Existence of a successful technology does not preclude development of newer technologies either. Pre-implantation genetic diagnosis [first used in the mid 80s] is a newer technique, which is technologically more demanding, invasive, requires persistence on the part of the couple, is much more expensive and is unlikely to be as popular as ultrasound in India. Moreover, the advantage that it does not necessitate abortion, is not likely to be perceived as a significant benefit, since the Hindu majority in India do not have major qualms about abortion.

Other forms of Assisted Reproductive Technology (ARTs) are similar to PGD in many aspects, and are unlikely to be available on a mass scale in the near future. However, predicting trends and the likelihood of spread of other technologies is an urgent need.

Challenges for the Campaign

The campaign against sex pre-selection and selective abortion faces major challenges today. Although it is clear that increased import and domestic production of ultrasound scanners is directly contributing to falling sex ratios, restrictions on import and manufacture of this equipment does not seem to be a feasible campaign strategy, since ultrasound is used also for other medical diagnosis. The inadequacy of the 1994 legislation, in terms of definitions, applicability and implementation triggered a campaign to amend the law and make it more comprehensive, as well as more practically applicable. The answer does not lie in more stringent legislation, but in implementing the current piece of legislation.

The recent conviction under the Act is positive news. A full twelve years after the law was enacted and 4000 cases later, the first conviction with a prison term was awarded on March 28, 2006 under the Pre-natal Diagnostic Techniques (Regulation and Prevention of Misuse) Act. A court in Faridabad, near New Delhi, found Dr Anil Samaniya and his assistant guilty of carrying out tests on pregnant women at his ultrasound clinic for years. They were sentenced to two years in prison and a Rs 5000-fine in Palwal, Haryana. Punjab has seen one conviction to date — Dr Neelam Kohli of Ropar district was fined Rs 1,000 by the Kharar court in July, 2003. Dr Samaniya’s conviction should send the clear message to the medical fraternity that those who profit from society’s hatred of female children, will be severely dealt with and put behind bars.


*Presentation made by Saheli at Sex Selection: Technologies, Populations and Social Relations, a two-day Seminar at Teen Murti Bhawan, organised by NMML, Action India and CWDS, 23-24 January, 2006, and subsequently presented at student awareness seminars in north and south campus of Delhi University.