There's a simple reason India's pregnant women are missing vital ultrasound tests

Last month, the Supreme Court rejected the plea of a 28-year-old Mumbai resident to terminate her 27-week malformed foetus. A committee of doctors at KEM Hospital instituted by Supreme Court to look into the case concluded that the woman’s foetus will have severe physical anomalies compromising the child’s quality of life when born. “The child will have severe physical and mental morbidity on survival,” said the committee.

The woman claimed that her doctors never advised her to have a foetal utrasound at the 18th week of her pregnancy that is vital to detect anomalies. “I was never told one needs to undergo an anomaly scan before the 18th week,” she told The Times of India. “Every time I went to the municipal hospital, a different doctor would see me.”

The woman’s advocate Sneha Mukherjee, who works with the Human Rights Law Network, said, “This was her first pregnancy and she didn’t know about how many ultrasounds she has to undergo.”

The woman’s complaint of not receiving appropriate medical advice despite visiting a government facility during her pregnancy has drawn attention once more to huge information gaps in the public health system. “If she had undergone the 18th week ultrasound, the anomaly would have been picked up and she could undergo the abortion,” said a doctor privy to the case.

The Medical Termination of Pregnancy Act allows a woman to undergo an abortion before 20 weeks of her pregnancy. However, if she wants to have an abortion after 20 weeks, she needs to get permission from the courts citing the reason for the termination of pregnancy.

In the last few years, the Human Right Law Network has helped five women approach the courts, seeking permission to abort their foetuses. “In three cases, the court permitted the abortion because the foetus was not going to be born alive,” said Mukherjee.

However, in this latest case, the committee of doctors at KEM Hospital were of the opinion that the baby may be born alive at 27 weeks and may survive for “variable period of time.” The committee also pointed out that “it was not possible for the doctor to determine the period of time for which the baby is likely to survive.”

The 18th week ultrasound

Despite going to a government hospital, the Mumbai woman did not receive adequate ante-natal care. Healthcare providers including doctors and nurses are expected to give pregnant women information about check-ups and necessary tests.

Doctors said that the 18th week ultrasound which is also referred as an anomaly scan is the most important investigation, especially in India, since abortions are allowed only up to 20 weeks. An abortion is permitted beyond 20 weeks, only when “termination of such pregnancy is immediately necessary to save the life of the pregnant woman.”

The ultrasound procedure done between 18th and 19th week of conception can reveal such abnormalities that can help a woman or a panel of doctors decide whether a termination of pregnancy is advisable. Despite this, doctors said that many women visiting both private and public hospital skip the vital procedure. In most cases, women say that they were not aware.

Dr Ashok Anand, head of gynecology department at Sir JJ Hospital in Mumbai said that women who are registered with a hospital for antenatal care are regular with check-ups. “Majority of these women undergo all the vital ultrasounds during pregnancy,” said Anand.

But the problem lies with women who are not registered. “In this group, about 40% of women would have not undergone an ultrasound,” he said.

The rest may have had at least one ultrasound procedure, mostly advised by local maternity hospitals or their pregnant friends.

No uniformity

Most associations of gynaecologists and obstetricians have recommendations for the number of ultrasound procedures a woman has to undergo during pregnancy. However, there is no one fixed number or schedule.

The first ultrasound, doctors said is performed to confirm the pregnancy which is usually performed at seven or eight weeks of conception. At 12 weeks, an ultrasound is performed, which can help screen the foetus for Down’s Syndrome. Between 18 and 19 weeks, an anomaly scan is performed to rule out any abnormalities. At 28 weeks, an ultrasound is performed to monitor the growth of the foetus. Lastly, a scan is done at term, which again is to see growth and position of the full grown foetus.

The guidelines issued by the national health portal of the union ministry of health and family welfare recommend four ultrasounds at least. Meanwhile, the World Health Organization guidelines for antenatal care recommends “one ultrasound scan before 24 weeks’ of gestation.”

“The most important ultrasound is the anomaly scan as it helps us to screen for significant deformities in the foetus,” said Dr Nikhil Datar, a senior gynaecologist in Mumbai.

Datar was a petitioner on behalf of a rape victim who approached the Supreme Court to abort her 24-week foetus. She was permitted to undergo abortion by the court in July last year.

Uro-gynaecologist Dr Aparna Hegde said that pregnant women need to be walked through ante-natal care procedures. “We know that hospitals are overcrowded which makes it difficult for doctors to counsel patients,” she said. “But, we need to put the information across to the pregnant women and her family to ensure a healthy childbirth.”

Hegde runs a non-profit organisation Armman, which uses mobile technology to deliver messages related to ante-natal care to pregnant women. “We start sending voice calls reminding women about their ultrasound, a week before it is scheduled so that they are prepared.”

Datar said that if a woman had to choose one ultrasound test, it should be at 18 weeks.

Paucity of ultrasound machines

Most pregnant women rely on their doctors’ recommendations. “I would undergo an ultrasound whenever my gynaecologist asked me to go,” said Hiral Khakkar, who delivered a healthy baby girl last month. “I didn’t have much clarity on the minimum number of ultrasounds or what they are exactly meant for. But, I was regular with my check-ups.”

However, public health activists said that the paucity of ultrasound facilities in government hospitals make it impossible for women to even undergo the minimum number of recommended scans.

For instance, among all the government health facilities in Sangli district in Maharashtra, there is only one functional ultrasound machine at the Government Medical College in Miraj town. “All women go to private sonography centres,” said an accredited social health activist or ASHA. “It is better to spend Rs 500-600 and get the sonography done here than traveling to Miraj. There are so many women waiting for a sonography there. Our chance may not come.”

A health activists working with Jan Arogya Abhiyaan, a network of health organisations, said “We know of women who have not undergone a single ultrasound because they didn’t have money.”

The Pradhan Mantri Surakshit Matritva Abhyan launched in 2016 is a programme by with doctors at private and government facilities provide free ante-natal care to pregnant women on one day every month. This programme doesn not, however, offer ultrasound investigations and check-ups are restricted to physical examinations. “No one is offering free ultrasounds,” said the ASHA worker.

Arbitrary abortion deadlines?

A committee constituted by the health ministry has recommended an amendment in the existing law governing medical terminations of pregnancy to allow abortions up to 24 weeks instead of 20 weeks. The committee did not have a representative from the medical community.

“Now, if at 19 weeks a significant anomaly is detected than the mother has just one week to decide and undergo an abortion,” said Datar who believes that a 24- week deadline will help such women. But, he thinks that this new deadline would still be arbitrary.

“The potential of the foetus to survive is to be considered while deciding the deadline,” explained Datar. “Generally, foetuses born after 26 weeks have a better survival so extending the deadline for termination a little further is needed.”

He added that there is an urgent need to create a system to ensure that all pregnant women get information about ante-natal care. “Why should anyone depend on doctor for information?” he asked. “If for any reason the pregnant woman misses the deadline for no fault of hers, ultimately she has to bear the brunt.”