‘It Happens a Lot’: The Flaws in India’s Sex Ratio Data and 'Gender Test' Law

It's hard to estimate the sex ratio from small studies. It has to be large datasets like the Census, say experts.

Sex-selective termination of pregnancy in India: Why has India's sex ratio not improved despite stringent laws around sex determination?

(Photo: Aroop Mishra/The Quint)

Ranjan (name changed on request), a 38-year-old man from Maharashtra's Kolhapur, is rather forthcoming when he says, "We got a test done to confirm the sex of our unborn baby."

He's aware that the procedure is illegal in India. "It happens a lot," he claims.

"There is a whole parallel 'set-up' for this. Not just in my town, but in other places too. I know others who have gotten it done."

Ranjan (name changed)

In 1994, India criminalised sex determination tests under the Pre-Conception and Pre-Natal Diagnostic Techniques (PC-PNDT) Act to put a check on female foeticide. In these 30 years, though India's sex ratio has improved, "it hasn't as much as it should have," say experts.

From 2001 to 2011 (the last time the Census was conducted), the sex ratio improved from 933 to 943. That is a dismal improvement by only 10 points. During the same period, some states have seen a plateau, and even a slight decline, in the sex ratio.

Data source: Census of India 2001 and 2011.

(Photo: The Quint)

More recent data released by the Haryana government in October showed that the state recorded a sex ratio of 905 till October 2024 – the worst it's been in eight years.

This, despite enthusiastic schemes like the Beti Bachao, Beti Padhao, and the fact that sex determination — the primary tool facilitating the termination of female foetuses — has been strictly outlawed, and devices used for sex determination have been heavily regulated.

So, where are we going wrong? Why is India's approach to stop female foeticide not working?

'But Data Says India's Sex Ratio Has Improved....'

To begin with, we don't actually know what India's current sex ratio really is.

As per the NFHS-5 (National Family Health Survey-5) data, India's sex ratio in 2021 was 1,020. This means that there are 1,020 females for every 1,000 males.

While the news was hailed by the government as a victory, experts say the numbers aren't entirely accurate – and the NFHS isn't the best source for estimating sex ratio either.

For one, the scope of the data collected in the NFHS is limited.

Speaking to FIT, KS James, former director of the International Institute for Population Sciences who led the fifth round of the NFHS in 2019-21, explains,

"The surveys are conducted only in households and not in institutional populations, such as hostels where students stay, old age homes, and homeless shelters. Therefore, the NFHS sex ratio reflects only the household population covered by the survey and may not be the country's real sex ratio."

The Women and Men in India 2023 report released by the Ministry of Statistics and Programme Implementation in August projected India's sex ratio in 2021 to be 945, contradicting the NFHS data.

According to the report, India's sex ratio is expected to reach 952 only by 2036.

James explains a possible reason for this discrepancy could be the sampling method used by the NSSO (National Sample Survey Office).

"The sampling method significantly influences the sex ratio computed from the survey. I understand that the NSSO fixes the sampling and other frames based on the 2011 Census, and they blow up their sample by appropriate weights to reflect the 2011 Census population characteristics. Therefore, it is not surprising that the NSSO sex ratio remains nearly as close as the 2011 Census. However, the NFHS sampling methods are slightly different."

Since 1881, the Census has been India's primary source for estimating the country's sex ratio. Since the Census was last conducted in 2011, we are staring at a data gap of over a decade.

FIT has previously covered this in detail here.

"We don't have any data after 2011. It's very difficult to estimate the sex ratio from small studies. It has to be large datasets like the Census," Poonam Muttreja, Executive Director of the Population Foundation of India, tells FIT.

How Do Indians Circumvent the Law?

Remember Ranjan? After the birth of his twin boys, contrary to what one might expect, he says his family had been desperate to have a girl.

He says,

"Because there aren't any girls in the whole family. They were insistent on us trying for a girl. My wife was keen too. So, I agreed to try for a third child. But we needed to be sure this time because if we have another boy, it would be a huge burden for us."

Ranjan (name changed)

Describing the process, Ranjan says, "We approached a doctor. He said it can't be done, it's illegal. But then, the next day I got a call from one of the ward boys in that clinic. He said he could help."

Ranjan goes on to say that it was a very 'shady' affair.

"At night, we were asked to go to one location. From there (my wife) Ratna (name changed) was taken by them to a different location where it was done. I wasn't allowed to go with her."

Ranjan (name changed)

"Ratna described the place to me later saying it was a small room in an under-construction mall with a table and a sonography machine," he adds.

Didn't she feel unsafe? "She was scared," he admits. "But we had to do it. And all the people involved were people we'd already come to know at the hospital, so we just hoped we could trust them."

"This is how it happens everywhere. People have these illegal setups in an ambulance or a non-descript van. Sometimes they get raided, but then others will pop-up. My friend's brother who is a gynaecologist also does it. He has done it for my sister, and a friend who wanted a boy."

Ranjan (name changed)

One might wonder why practicing medical professionals would risk losing their license and criminal prosecution to offer this service under the radar.

Well, there's money in it. Ranjan says that the one sonography session cost him a whopping Rs 50,000. For reference, a regular ultrasound scan costs anywhere between Rs 700 and Rs 2,000.

There is also the fact that in practice, the law is really difficult to enforce.

"While there is a fear of the PC-PNDT Act, it's not effectively implemented on the ground. Doctors and technicians may not put the sex of the child on paper, but indications are given. We know this happens a lot," says Muttreja.

There have also been several reports in the past of affluent, urban Indians who can afford it make trips to other countries like Thailand where sex determination is legal, to get the test done.

The Trouble with India's Sex Determination Law

The law's failure to curb sex determination is probably one reason why many doctors are now advocating for the legalisation of sex detection.

"This law is almost three decades long, and it is very obvious that it has not been helpful in achieving its goal," Dr RV Asokan, President of the Indian Medical Association (IMA), tells FIT.

Dr Asokan is at the forefront of an emerging movement of medical practitioners calling for the legalisation of sex determination. Speaking to the press in October, he argued that while improving India's sex ratio is a common goal, the law has done more damage than good.

"Because of the ban, there is no official record of the sex of foetuses. So, when a pregnancy is terminated, there is no way of connecting it to sex-selective termination. How do you presume a crime?"

Dr RV Asokan, President, IMA

According to him, legalising sex detection will make it possible to 'tag' pregnancies and maintain records (proof) of the sex of each foetus. "If there is an unaccountable interruption, do prosecute the perpetrators."

"The interpretation of the act at every level has been very non-uniform," adds Dr Harsh Mahajan, former national president of the Indian Radiological and Imaging Association.

What constitutes as 'sex determination' under the law is a broad range of actions and varies from state to state, and in some cases even district to district. "For instance, the punishment for missing form F* for any scan is the same as if you are caught doing sex detection," he adds.

Doctors are also unhappy with how the law restricts the use of these essential, oftentimes lifesaving, medical devices in India.

The PC-PNDT Act prohibits the sale of imaging machines or scanners to anyone not registered under the Act, severely restricting their use. However, the Act does not specify which machines are covered.

"Even CT Scan and PET CT Scan have been brought under the gambit of this law in certain states. This means that anyone who wants to install and operate a CT Scan machine has to take clearance under the PC-PNDT Act. It makes us a laughingstock in the world," he adds.

"All doctors that use any of these diagnostic tools are harassed by patients and by the law. Even cardiologists, who have nothing to do with pregnancies, face this because they use these machines."

Dr RV Asokan, President, IMA

Dr Asokan adds that the wireless handheld ultrasound machine — a 'revolutionary device' that doctors can carry like the stethoscope to diagnose a wide range of medical conditions like heart disease, internal injuries and even cancer in minutes — has become an indispensable part of medical practice in other countries. "Our patients are being denied this technology, just because of this law."

Debanjana Choudhuri, a gender rights activist, tells FIT that several legal abortion clinics also came under fire when the PC-PNDT Act was put in place.

"Many genuine cases of distressed women seeking safe abortion were denied their right. So, the PC-PNDT completely conflates with the MTP Act (Medical Termination of Pregnancy Act, 1971)."

Debanjana Choudhuri, gender rights activist

However, other experts warn that the solution to tackling the kinks isn't to scrap the law altogether. "The PC-PNDT Act is a necessary deterrent. Legitimising the test will be sending out the message that it is alright to find out the sex of the child," says Muttreja. "Regulation in India is so poor that we are not going to be able to control it even if we have the information."

"Sometimes, even the technicians and the doctors have a son preference, so they don't feel any qualms about supporting a woman or a family to get rid of a female child. So, these social biases play up at every level."

Poonam Muttreja

Moreover, she points out that such a move will create chaos for legitimate cases of abortion.

In India, where the burden of birth control is almost entirely on the woman, abortion is often used as a proxy for contraception. Fortunately, women in India today can access abortion no-questions-asked (up to 24 weeks of pregnancy). "But if sex-determination is legalised, it will become a huge challenge for these women. How will you know if the abortion was spontaneous or related to the sex of the child?" she says.

Adding to this, Dr Mahajan says, "If the ban under the PC-PNDT Act is to continue, then we need to digitise the whole process right from the equipment manufacturing, to installation, to the use of the machines. Then we can keep a better check on the misuse of ultrasound devices and bring about uniformity in the implementation of the law across the country."

Addressing the Real Issue

India's approach to tackling female foeticide doesn't address the underlying reasons for the intent behind the action.

"Son preference is beyond a medical issue; it is a social issue," says gender rights activist Choudhuri. "It isn't surprising that the sex ratio hasn't improved despite the PC-PNDT Act, because we haven't done enough to curb son preference."

"As long as people believe that it's better to have boys over girls, things are not likely to change. This preference stems from deep-rooted stigma and the unequal status of women in the society, and that discourse is missing."

She notes that even some of the campaigns run to encourage the birth of girl children inadvertently reflect this. "There was one slogan that says, 'Ladkiyan nahi bachaoge toh kal roti kaun banaegi' (if you don't save the girl child, who will cook for you in the future?). So even when they mean well, the value of women is reduced to cooking, or their child-bearing capacity," Choudhuri says.

Muttreja adds that most schemes, like the Beti Bachao, Beti Padhao campaign – which will complete 10 years next year – and the Dhanlakshmi Scheme (a conditional cash transfer scheme), are launched with fanfare but have suffered due to insufficient on-the-ground monitoring during its execution.

"The government does not evaluate the schemes or does course corrections. So, they fail to address the gaps in these schemes. It is very important to have indicators on how you're going to measure the impact, and then you need to have a framework to assess the impact."

The Comptroller and Auditor General of India reports for Haryana and Punjab released in 2019 also highlighted underutilisation of funds and ill-conceived fund allocation (only 5 percent of the funds was allocated to education while 47 percent was used for communication-related activities), as reasons for the scheme's failure.

"In Haryana, when we were part of an impact assessment of the Apni Beti, Apna Dhan Scheme, people thought that the conditional cash transfer was for their dowry if you didn't get your daughter married off before they turned 18."

Poonam Muttreja

"There, we found that there was no message about educating the girl child and making her financially independent. The message was just that you'll get money if you don't marry your daughter off before she turns 18," she says.

"It can't be just slogans, incentives, or legal enforcement. The messaging should be strong and clear", she adds.

*Form F is part of the paperwork that all technicians and doctors who are using any of the machines that fall under PC-PNDT act have to fill out and maintain for record.