The global male-to-female sex ratio at birth is slightly in favour of boys than girls, but if both sexes receive similar nutrition and care, females have a higher chance of outliving their male counterparts as is evident in the industrialised world.

However, this does not hold true for all parts of the world, and many developing regions are experiencing the phenomenon called the “missing women.”

This was highlighted in a landmark paper, More Than 100 Million Women Are Missing, by renowned Indian economist Amartya Sen almost two decades ago.

His observations for countries in South Asia, West Asia and China at that time still hold true for these regions. Sen attributes this phenomenon to the economic and social conditions that contribute to the neglect of women as compared to men.

In many parts of the world, preference for the male child, perhaps based on the misplaced notions of the greater utility of the male child, manifests itself in numerous ways, from providing better nutrition, to better education and even preferential access to healthcare.

The deck, on the other hand, is stacked against the girl child even before her birth. Whereas all forms of gender discrimination are unacceptable, one of the most alarming ways the preference for the male child plays out is in the form of gender-based abortions.

While gender-based abortions are well documented in other countries and countermeasures are also visible, such practices are not even acknowledged as a problem in Pakistan. It is for this reason that this area has not been the subject of the kind of public scrutiny that it deserves.

Some independent work has been done which sheds light on this issue in this country. A study by the Population Council Pakistan some time back noted that the number of abortions had increased substantially in the period between 2002 and 2012 in Pakistan.

According to the study, out of 4.2 million unintended pregnancies during those 10 years, 54 percent ended in planned abortions.

While we cannot comment with certainty regarding the sex of the aborted fetuses, numerous personal accounts from healthcare professionals indicate that female fetuses were more likely to be aborted.

In-depth: No country for girls

In the hands of an experienced operator, a routine antenatal ultrasound examination of the woman makes it easy to conclusively detect the sex of the unborn child between 14-16 weeks of pregnancy. Cognizant of the risks, Indian law bars ultrasonologists from revealing the sex of the fetus to the parents.

In Pakistan, the Code of Ethics by Pakistan Medical and Dental Council (PMDC), the governing body for medical education and practice in the country, also requires medical practitioners to not disclose the gender of the fetus, unless “it is absolutely sure that no harm shall come to the baby and the mother as a result of this disclosure.”

Since it would be practically impossible for the ultrasonologist to reasonably ascertain actual risks of revealing the sex of the fetus during the single encounter she has with the pregnant woman and her accompanying attendant, we believe the wording of the PMDC code leaves a very dangerous window open for misuse of this clause.

Sophisticated blood tests are now available in Pakistan that can, as early as nine weeks of pregnancy, make a sex determination of the fetus by seeking out traces of fetal DNA circulating in maternal blood.

Since early termination of pregnancy is generally considered less morally and psychologically problematic than an abortion carried out later in term, these tests may have a potential of being misused for the purposes of performing sex-selective abortions, unless used with caution and for valid medical purposes.

Even when qualified healthcare professionals may refuse to terminate pregnancies based on the sex of the unborn child, the existence of entirely undocumented back alley abortionists raises another challenge.

Midwives (dais) and quacks provide such services, the costs of which can be much more than just monetary, with unhygienic procedures that can lead to major infections or even death of the mother.

And if aborting fetuses seems unpalatable, sophisticated fertility centres in Pakistan are offering, overtly and covertly and at an additional cost, ‘value added services’ of gender selection at the time of conception, by implanting the desired fetus in the mother’s uterus through In Vitro Fertilisation (IVF) techniques.

This is also in violation of the code of medical ethics by PMDC, which state, “the choice of gender by any means shall be illegal.”

To the best of our knowledge, no IVF centre offering gender selection services has ever had any legal troubles despite clearly violating the PMDC code of conduct.

Read more: IVF clinics — in business big time

Another worrying trend in gender-selection processes that has recently emerged involves offering these services packaged as ‘sharia-compliant’ processes.

While all religions uphold the sanctity of life, it is ironic that these services misuse the name of Islam, a religion that unequivocally condemns this very practice of discrimination against the girl child.

These ‘sharia-compliant’ procedures, at a cost, ‘guarantee’ at conception a baby of the desired gender, which is medically nonsensical.

Whereas it is problematic that our society subscribes to such archaic practices, it is even more alarming to note that the highly educated medical community is prepared to offer such services.

While we acknowledge that medical practitioners do not practice in a social vacuum – their own values and that of the society around them also reflect their conduct – society holds the physicians to a higher moral standard and healthcare professionals have a greater responsibility to display moral conduct.

It is unacceptable for medical practitioners to barter the sacrosanct oath they took upon their initiation into this noble profession, and offer their services for gender-selection processes in order to make some easy money. This defies the values that medical practitioners are required to uphold as part of their profession.

Medical codes are drawn up to guide the conduct of healthcare professionals, but regulating bodies need to take note that codes of conduct with no teeth have no chance of being effective. Lack of enforcement mechanisms seriously limits the utility of such codes of conduct.

In addition to having guidelines, and their proper enforcement processes, we need to train our physicians to tread the high moral ground. This can only happen when in addition to their technical training, they are also educated in bioethics and humanities in order to become more humane practitioners.

The process of resetting societal trajectories is a long and arduous one, and has to be addressed on multiple fronts in order to move towards a fair social order.


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