“It is He (God) who created you from a single person, and made his mate of like nature, in order that he might dwell with her (in love)….” (al Qur'an 7:189)
Gender composition (female-to-male ratio) of J&K population in the recently released national census report-2011 has sent shock waves. While the sex ratio at the national level has risen by from 933 females per 1000 males in 2001 to 940 females per 1000 males  in 2011 (a rise of seven points); the corresponding  sex ratio in J&K has dropped from 892 to 883 (a drop of nine points). Shockingly child sex ratio (0 to 6 years) in J&K has dropped from 941 to 859 females per 1000 males (a drop of 82 points) during this period. Lowest sex ratios were recorded in Leh (583; drop of 240 points) and Kargil (584; drop of 239 points) and highest in Kulgam and Shopian (951; 11 points above national average). Jammu (871) and Srinagar (879) have registered improvements over the 2001 figures.  Selective disappearance of females could lie in selective male fertilization for unexplained reasons, female feticide through ultrasound prenatal sex determination, selectively poor nutritional and medical care of girl-child leading to high female infant mortality, and possibly a combination of the above. The present society in J&K can be compared to pre-Islamic Arab world which has been aptly depicted in the Quranic verses “When news is brought to one of them, of (the Birth of) a female (child), his face darkens and he is filled with inward grief! With shame does he hide himself from his people because of the bad news he has had! Shall he retain her on (sufferance) and contempt, or bury her in the dust? Ah! What an evil (choice) they decide on? (Al Qur'an 16: 58-59).”
Society needs a comprehensive program to reverse this mindset. Our targets should be: those boys (to shun from dowry); husbands (to love and care); families (to accommodate and accept the newlywed); brothers (to stand by her always); society (to give her dignity); police and judiciary (to hear her in pain) and Imams and elders (to protect her rights) and many more. Society has to change to accept birth of a girl-child as a blessing rather than a curse, as is realized now in the Arab World.  For bringing up a girl-child, Prophet Mohammad (PBUH) said “Whosoever has a daughter and he does not bury her alive, does not insult her, and does not favor his son over her, God will enter him into Paradise and whosoever supports two daughters till they mature, he and I will come in the Day of Judgment as this (and he pointed with his two fingers held together).”
Next, what to do to the alleged issue of prenatal sex determination and possible selective female feticide? Administration has woken, come up heavily and sealed scores of ultrasound units for (what health authorities call) not complying with the defined norms and for want of PNDT (Pre Natal Diagnostic Testing) certifications. While debate on the ultrasound unit guidelines and who should do the ultrasound shall continue to make rounds in the society, a number of issues related to obstetric ultrasound need to be highlighted and parents should be aware of these while planning for the next baby. 
It is now a standard of care that every pregnant woman should have 4 to 5 fetal ultrasound examinations. These are named as: (1) First trimester ultrasound, (2) 11 to 14 weeks ultrasound, (3) 18 to 24 weeks ultrasound, (4) 32 weeks ultrasound, (5) 36 weeks ultrasound. Each examination is done with specific questions in mind about the progress of the pregnancy and answer to these questions need to be specifically documented. Fetal ultrasound has gone through a revolution in the recent past and the examination must answer, apart from progress of pregnancy, about fetal malformations and anomalies.  This is important as congenital malformations are diagnosed in 4 to 8 percent of infants in the first year of life and these are single leading cause of infant mortality in the West. First trimester ultrasound is performed to confirm intrauterine pregnancy, to estimate gestational age, to confirm fetal viability (cardiac activity), to name a few. Trans-abdominal ultrasound is usually adequate; however, trans-vaginal ultrasound may be desirable in some circumstances.  11 to 14 weeks mainly checks fetal skull and intracranial structures, screening large defects, such as children without brain, etc. This scan is important to assess the risk of Down’s syndrome and other chromosomal abnormalities. This risk is calculated by taking in to account age of the mother, measurement of 2 hormones (triple test) and scan findings of nuchal translucency thickness, nasal bone and fetal abnormalities. 18 to 24 weeks ultrasound is a level 2 study and does a fetal anatomy survey (examination of all body structures and organs of the fetus) to define any fetal anomalies.   This examination includes examination of sex organs and possible anomalies in these structures (sex differentiation disorders).  Several anomalies in sex organs can be diagnosed which include Ambiguous genitalia (associated with adrenogenital syndrome in female fetus), hypospadias/epispadias, torsion testes, and scrotal intestinal hernia (in male fetus) and ovarian cysts, vaginal malformations, etc (female fetus). Sex determination is necessary in assessment of sex linked hereditary disorders especially hemophilia, wherein females transmit the disease and males only suffer.  32 week examination needs to integrate the previous two results, to make up for the omissions in the previous examinations, such as in the fetal late period, tumors and so on may appear, which must not be taken lightly. 36 weeks is the last examination before birth, mainly related to weight, placenta, and amniotic fluid examinations, preparing for childbirth.
Thus in the state of art level 2 (18 to 24 weeks) ultrasound examinations of the fetus, it is mandatory to examine sex organs in every fetus. Problem arises when parents want to know the sex of the baby and use this for an immoral and unpardonable crime of female feticide and doctors for many reasons fall a prey to this sinful and immoral disclosure. Let us examine the question “How accurate is sex determination of the fetus?” It has been repeatedly stressed in literature by well done studies that determination of prenatal sex through ultrasound is subject to many variables and can be grossly fallacious.  Determination of prenatal sex is dependent upon the equipment quality and type of ultrasound probes, age of pregnancy and of course expertise of the operator.   Inappropriate fetal position, excess amount of amniotic fluid and increased thickness of the abdominal wall of the mother can grossly adversely affect prenatal sex determination.  Many times the genital tubercle of the female if prominent can look exactly like male organ and vice versa. Sometimes umbilical cord in a female fetus may resemble male organs and give fallacious results. Thus chance of making a correct prenatal sex determination at 11 weeks of pregnancy is around 50 percent. This is so when excellent ultrasound machine with high quality probes and well experienced sonologist is doing a careful examination. So, if a sonologist declares the baby as female, there are half chances that the baby may be male and vice versa. As the pregnancy grows the chances for correct sex determination are better but never reach 100 percent. Within the system we are conducting our obstetric ultrasound; I believe prenatal sex determination may be correct in less than one third of pregnancies. So the dictum that best way to determine sex of your baby is at birth has been repeatedly stressed in medical literature.  I believe this fact should be known to parents and do not attempt fetal sex determination for other than medical reasons. Several families have suffered by causing feticide of a male baby while ultrasound report was leaked out as female baby.
We as a society must remember that equality between women and men is a matter of human rights and a condition for social justice and is also a necessary and fundamental prerequisite for equality, development and peace. There is no text, old or new, that deals with the humanity of the woman from all aspects with such amazing brevity, eloquence, depth, and originality as in this Quranic verse "O Mankind, keep your duty to your Lord who created you from a single soul and from it created its mate (of same kind) and from them twain has spread a multitude of men and women" (Al Qur'an 4: 1).  Let us pray that God shows us path of righteousness and we do not indulge or associate in any way in those acts which are harmful to humanity and detrimental to our beliefs-Ameen.

(Professor Muhammad Sultan Khuroo, MBBS, MD, DM, FRCP (Edin.), FACP (USA), Master of the American College of Physicians (Emeritus), is Director, Digestive Disease Centre, Dr. Khuroo’s Medical Clinic, Srinagar, Kashmir.  E-mail: Khuroo@drkhuroo.org, Website: www.drkhuroo.com)

Lastupdate on : Tue, 7 Jun 2011 21:30:00 Makkah time
Lastupdate on : Tue, 7 Jun 2011 18:30:00 GMT
Lastupdate on : Wed, 8 Jun 2011 00:00:00 IST