Pre-Conception & Pre-Natal Diagnostic Techniques (PC&PNDT) Act 1994 is an act enacted by Parliament of India came into existence to stop female feticide and to maintain sex ratio in India. Under this act, pre-natal gender identification is banned. No Pre Natal-Diagnostic Tests should be conducted for identification of gender of foetus.1

PCPNDT Act also regulates the diagnostic procedures like Ultrasonography, Fetoscopy. As per the act, no Pre-Natal Diagnostic Techniques shall be conducted except for the purpose of detection of Chromosomal abnormalities, genetic metabolic diseases, haemoglobinopathies, sex linked genetic disease, congenital anomalies, or any other abnormalities.2

As per the latest census sex ratio in India is 943 females per 1000 male. The child sex ratio was 919 females per 1000 male in 2011.3 In Past five years, Karnataka has seen 978 girls born for every 1,000 boys, as per the recently released National Family health Survey (NFHS-5) 2019-20.4 As per the latest census the sex ratio of Bangalore is 916 females per 1000 males.5 Due to the declining sex ratio in India PCPNDT act was enacted to prohibit female feticide and to maintain balance between the two genders.

The act prohibits sex discrimination both before and after conception. As per the act any person, who is involved in such activities which violates the rules mentioned in the act, shall be punishable with an imprisonment of 3years which may extend up to 5yrs and a fine of 10,000 to 50,000 which may extend to 1,00,000.2

Various studies have been done in the past with regards to PCPNDT Act, however the impact of this law on the society is a continuous ongoing process. This study is being conducted to assess the awareness among women of reproductive age group about PCPNDT Act and to study the impact of PCPNDT act on the attitude of the people regarding sex ratio, after its inception almost 30 years ago. 

OBJECTIVES:

1. To assess the knowledge among women of reproductive age group about Sex Ratio and PCPNDT Act in India.
2. To know the attitude of women of reproductive age group regarding Pre-natal sex determination and its impact on sex ratio

An Observational, Cross-Sectional study was conducted at Vydehi Hospital, Whitefield, Bangalore for 4 months period that is from September to December 2023 among women of reproductive age group 15-49years visiting obstetrics OPD for antenatal care. Those who gave voluntary consent to participate in the study were included in the study. Those who have any complications like chronic diseases and not willing to participate in the study were excluded from the study

Sample size was calculated by using formula,

 N = Z²_1-2÷2 P (1-p ) ÷ E²

n=1.96^2*0.3249(1-0.3249) ÷0.08^2 = 132

Were,

              1.96, standard normal score at 95% level of significance.

              P = Proportion (The proportion of women having knowledge of 32.49%) (from

                     related article)

              E = 8%, margin of error

The minimum sample size is 132.

After obtaining ethical clearance from Vydehi Institutional Ethics Committee to conduct a study, written consent were obtained from the patients for their voluntary Participation. Patients who were not willing to be part of study and have any complications were excluded. Total 248 patients visited obstetric OPD for antenatal care during study period among which 132 women of reproductive age group who fulfills the inclusion criteria were included in study.

A pre-tested semi-structured questionnaire (after pilot study of 20 participants) validated by internal and external evaluators was given to the participants. Data collected were in two parts namely Socio-demographic profile; knowledge and  attitude among women of reproductive age group regarding sex ratio, pre-natal determination of sex and PCPNDT Act. 

STASTISTICAL ANALYSIS

• Data collected was entered in MS-Excel and analyzed using SPSS version 23.
• Mean and Standard deviation will be used for continuous data.
• Frequency and Percentage will be used for categorical data.
• Chi-squared test and Fisher’s exact will be used to see the association between the categorical variables.
• P<0.05 will be considered as significant.

The assessed data has been represented as self-explanatory tables and graphs below.

Fig.1 shows majority of the women of reproductive age group i; e 74 out of 132 (56.1%) in present study were aged between 21 to 30 years followed by 31 to 40 years (21.2%) and 17% were 41 and above years

Figure 1: Age-wise distribution of study participants (women of reproductive age group)

Table 1: Distribution of socio-demographic profile of study participants

Table 1. shows majority of our study population are graduated accounting for about 50 (37.9%). Though majority were graduates, 86 out of 132 were unemployed (65.2%). 43 out of 132 (32.6) belongs to Upper middle class (class II) according to modified B G Prasad’s classification followed by 19.7% who belong to lower middle class and 87 out of 132 were residing in urban accounting for 65.9% and rest 34.1% were from rural places.

Table 2: Distribution of participants based on their knowledge about the sex ratio

Table 2. shows 72 out of 132 (54.5%) participants were aware about sex ratio and 71 out of 132 (53.8%) knows the current adult sex ratio whereas only 50.8% were knew about child sex ratio in India

Table 3: Association b/w participant’s education and their knowledge about sex ratio

*p value is obtained from two-sided Fisher’s exact test; percentages are calculated based on row total

Table 3. shows association b/w participant’s education and their knowledge about sex ratio and Table 4. shows the knowledge of study participants regarding PCPNDT Act. 114 participants out of 132 (86.3%) were aware that prenatal sex determination is punishable under PCPNDT Act and only 29.5% knew about imprisonment or fine as punishment under the Act. 57.6% were aware that prenatal sex determination is done by ultrasonography and only 49.2% participants knew that foetal sex determination is done in other countries

Table 4: Distribution of participants based on their knowledge regarding PCPNDT Act

Table 5: Association b/w participant’s education and their knowledge about foetal sex determination and PCPNDT Act

*p value is obtained from two-sided Fisher’s exact test; percentages are calculated based on row total

Figure 2: Distribution of study participants (women of reproductive age group) according to knowledge of place where foetal sex determination is conducted

Figure 3: Distribution of study participants (women of reproductive age group) according to the knowledge of persons punishable under PCPNDT Act

Figure 2. shows the knowledge of study participants regarding place where prenatal sex determination is done in India whereas Figure 3. shows knowledge of participants regarding persons punishable under PCPNDT Act.

Figure 4: Distribution of study participants (women of reproductive age group) according to source of information about foetal sex determination in India

Figure 4. shows the source of information for the study participants regarding foetal sex determination in India. Majority of participants source of information are friends and relatives (7.6%) followed by internet and mass media.

Table 5: shows association between participant’s education and their knowledge about foetal sex determination and PCPNDT Act in India and Table 6. shows the attitude of study participants towards pre-natal sex determination. 97.7% participants are willing to educate people and encourage against prenatal sex determination and 95.5% participants wants to continue of PCPNDT Act. 92.4% participants agree that violators under Act should be punishable.

Table 6: Distribution of participants based on their attitude towards pre-natal sex determination

Table 6. shows the attitude of study participants towards pre-natal sex determination. 97.7% participants are willing to educate people and encourage against prenatal sex determination and 95.5% participants wants to continue of PCPNDT Act. 92.4% participants agree that violators under Act should be punishable.

In the present study, 24 out of 132 (18.2%) felt that fetal sex determination is commonly done at Private hospital. 17 (12.9%) felt that it is carried out at all health centers such as Government hospital, Private hospital, Scanning Centre. Hardly 29 (22%) of the study population knew about PCPNDT act yet 114 (86.3%) were aware that fetal sex determination is punishable but did not know under which act. 55 (41.7%) knew that Doctor, Mother, Father, Other Family Members will be punishable for sex determination of the child.

Of 132 participants, 22 (16.7%) of them felt that only the doctor who is determining the sex is punishable. 12 (9.1%) had felt that only Mother, Father and other Family Members encouraging this would be punishable. 39 out of 132 of them knew that both Imprisonment and Fine has to be paid as punishment and 28 (21.2%) had felt that Imprisonment is the only punishment.

Table 7: Distribution of participants based on their knowledge regarding consequences of decreased female sex ratio

Table 7. shows 36.3% participants says decrease in female sex ratio leads to social imbalance and 24.2% says there will be shortage of brides for men in future whereas 18.9% says there will inefficient running of family.

In the present study, majority of the females were aged between 21 to 30 years that is 74 out of 132 (56.1%) followed by 31 to 40 years (21.2%). Similarly, in Gaur NK et al mean age of the females participated in the study was 27-28 years and majority of them were aged above 18 years at the time of their marriage.6

Number of females having graduate degree was 50 (37.9%) followed by 40 (30.3%). 15 (11.4%) and 13 (9.8%) were completed their professional course and intermediate. Illiterates were 7 (5.3%) among our study population. Shidhaye et al had reported that 9 (75%) of their study population who didn’t know about the PNDT Act were Only 9 (75%) illiterates didn’t know about the PNDT Act. They even observed that as the education increased, the knowledge about sex determination and

the act increased (P < 0.01)., but as education increased, the knowledge about sex determination and the Act increased (P < 0.01).7

In our study, 86 (65.2%) of the females included in our study were unemployed and 13 (9.8%) were professionals followed by 11 (8.3%) were clerks and rest of the minor portion of their occupation is as mentioned in the Table 2. Educated Women with higher SES were aware of PCPNDT Act as per the report by Livingston LS et al.8  The study conducted by Mishra A et al. shown that, out of 2000 antenatal women, 43.08% had knowledge about PC & PNDT act & 56.2% did not have any knowledge about it. The more the literacy status, the more was the knowledge about PC & PNDT act. Illiterates had more preference for male child. The attitude regarding PC & PNDT act was more positive in the lower middle class.12

Regarding knowledge about PCPNDT act, 101 (76.5%) were confident that fetal sex determination is not done in India. Hardly 21 (15.9%) felt that fetal sex determination is done and the rest had no much idea about it. Friends and family relatives (10; 7.6%) were the most common source of information about fetal sex determination followed by internet, social media of other norms and both had been source of information among 3 (2.3%) of those who felt it is done in India. Even in Shidhaye PR et al,7 81 (77.1%) women knew that determining sex of the foetus as crime but only 49 (34.3%) women knew about the PNDT Act. Unlike our observation, 115 (80.5%) women participated in their study didn't know even know about the legal punishment for sex determination. Even in Gaur NK et al, 70(53.8%) of females weren’t aware about the act but were willing to impose a strict law 124(95.4%). Hence, there is need for more studies and educational programmes in this regard.6 There was significant corelation between education and socio-economic status and awareness and knowledge about Pre-Natal Diagnostic Techniques Act and Pre-Conception and Pre-Natal Diagnostic Techniques Act and Pre- Conceptional and Pre-natal sex determination. Majority of the women, (97%) women do not want routine sex determination9

Whereas 25 (18.9%) had idea that fine is the only part of punishment. 100 (75.8%) of the 132 females knew about female infanticide and the rest did not know. 25 (18.9%) of them opined that Social imbalance, Increased violence against women, Decreased brides for men, Inefficient running of the Family will be the major problem with imbalance in the sex ratio with decreased females. 10 (7.6%) each had mentioned it would lead to social imbalance with increased violence against women, Social imbalance with decreased brides for men and Social imbalance, Decreased brides for men as well as inefficient running of the Family. Livingston LS et al8 observed that 71.4% were not aware of the declining sex ratio. Similar to our study, even among their study population, 79.1% were not aware of PC&PNDT Act and 49.1% didn’t know who can be punished under this act.

Sonal R Deshpande, et all., conducted a study on “Awareness and perception regarding PCPNDT Act and gender preference among mothers of under-five attending immunization clinic” in 2016 at Nagpur. They found that Majority of mothers 150 (75%) were aware about decreasing girl’s ratio in India. 161 (80.5%) mothers were aware about prenatal sex determination, and 61 (30.5%) knew that sonography is used for this purpose. Awareness about PCPNDT Act was 65%. Of 83 mothers desirous of more children, 33 (40%) preferred to have male child; while only 14 (17%) had preference for a female child.10 whereas in present study 101 (76.5%) were confident that fetal sex determination is not done in India. Hardly 21 (15.9%) felt that fetal sex determination is done and the rest had no much idea about it.

Dadwani Roma S, et all., conducted a study on “Knowledge Regarding Sex-Ratio and PCPNDT Act – A Cross Sectional Study” in 2014 at Gujrat. They found that 58% of total population was aware of adverse sex ratio. 86% of study population were aware of various sex determination method and 90% were aware that prenatal sex determination was illegal. 76% of study population were aware of PCPNDT Act, among them 96.7% of urban and 78.6% of rural population replied that prenatal sex determination is a punishable offence. 11% of urban and 40% of rural population were not aware of the punishment under the act.11 whereas in our study 87 out of 132 were residing in urban accounting for 65.9% and rest 34.1% were from rural places.

Mahendra Khatri, et all., conducted a study on “Knowledge, Attitude and Practices (KAP) Related to Pre-Conception & Pre-Natal Diagnostic Techniques (PC&PNDT) Act Among the Antenatal women” in 2012 at Bikaner. The study showed that 64.9% women have positive attitude towards the PCPNDT Act while only 35.1% have negative attitude. It was found that 98.8% of study population was willing to increase the awareness of PCPNDT Act.12  whereas in the present study 97.7% participants are willing to educate people and encourage against prenatal sex determination and 95.5% participants wants to continue of PCPNDT Act.

In our study, 8(6.1%) of the 132 knew that any friend / relative who has sought prenatal sex determination and one among them preferred not to answer that. Like our study, Shidhaye PR et al9 also observed that out of the 143 women, 86 (81.9%) knew about sex determination at the age group 20-30 years while out of them. Whereas only 33 (31.4%) knew about PNDT Act which is comparatively lesser than our study. About 9 (45%) above 30 years did not know about sex determination which was statistically significant.

Limitation of our study is we did not analyse the association between all demographic factors and the knowledge regarding PCPNDT Act of our study population

ACKNOWLEDGEMENTS

I would like to acknowledge the Principal of our institution, Dr Shreedhar Venkatesh and Medical Superintendent Dr Umamaheshwar for permitting us to conduct the study.

The study was conducted under the guidance and support of Dr Chaitali Gore, HOD, Community Medicine and Dr Aparna Nair, HOD, Gynaecology & Obstetrics so I would like to thank both professors. A special thanks to Dr Madhwa Prasad, Associate Professor, OBG department for continuous support and guidance.

I also like thank all our staff members of the both departments for support and guidance to conduct the above study and also VIEC members for giving valuable inputs and an approval for the study

I would like to thank Intern Medical officers and post graduate students who helped to collect data for the study and Biostatistician Mrs Chaitra for heling in statistical analysis of the study

I would like to special thank for all the participants who gave their valuable time and responses to make our study successful.

DECLARATIONS

Funding: None

Conflict of interest: None

Ethical approval: Approved from Vydehi Institutional Ethics Committee (VIEC)

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