Female infanticide: Raising awareness | Photo Credit: GOUTHAM P

India’s response to gender-biased sex selection has evolved through a combination of legal, regulatory and social interventions, from the PC-PNDT Act to nationwide campaigns aimed at improving the value accorded to the girl child.

At the heart of this framework lies the regulation of diagnostic technologies, particularly ultrasound, alongside efforts to create awareness among people on the deeper issue of gender discrimination and male preference

Legal architecture has steadily expanded over time. What began as a law to regulate prenatal diagnostic techniques was later strengthened to include pre-conception methods and ultrasound, alongside stricter requirements for registration, record-keeping and oversight. These provisions were intended to ensure accountability and prevent misuse. In principle, the approach is both necessary and justified.

Yet, the effectiveness of any law lies not only in its intent, but in its implementation. The execution of the Act, largely driven at the state level, has led to variations in interpretation and enforcement across jurisdictions.

Differences in procedural requirements, approval mechanisms, and the regulation of imaging technologies have introduced ambiguity in how the law operates on the ground.

Striking a balance

This brings into focus a central tension, how to sustain rigorous enforcement against a persistent social evil while ensuring that the regulatory framework remains proportionate and does not impede access to essential diagnostic services. Striking this balance is critical to the law’s credibility and effectiveness.

The law’s origins were justified and timely. India’s worsening child sex ratio, from 104 males per 100 females in 1981 to 109.4 in 2011 in the 0–6 age group, demanded decisive intervention. The Act remains a critical safeguard against sex-selective practices, which continue to persist in more covert forms. In many instances, violations involve unregistered operators using portable ultrasound machines outside formal healthcare settings. This reality underscores why constant vigilance and rigorous enforcement are indispensable.

Practical challenges

At the same time, variations in implementation have created practical challenges. In some states, the scope of regulated imaging equipment has been interpreted more broadly than intended, while procedural requirements for registration and approvals differ across jurisdictions.

Restrictions on the use of portable ultrasound devices, sometimes extending beyond central guidelines, have limited their deployment for non-pregnancy-related purposes, particularly in remote and underserved areas.

When compliance becomes difficult to navigate, unintended consequences can emerge. In some cases, practitioners are becoming more cautious about maintaining ultrasound facilities, especially in smaller clinics where administrative processes are harder to manage.

This can affect the availability of essential diagnostic services for patients who rely on timely ultrasound scans for routine monitoring, early detection, or emergency care.

Evidence from states such as Haryana suggests that enforcement alone is not sufficient. Improvements in the child sex ratio, from 834 to 923 between 2011 and 2022, have been driven by sustained awareness campaigns, incentive schemes, and investments in girls’ education. Legal deterrence plays an important role, but it works alongside broader social change.

Targeted enforcement

At the same time, stricter enforcement has, in some cases, pushed illegal practices further underground, with unregulated operators offering clandestine services without oversight. This reinforces the need for enforcement that is firm, but also precise and intelligently targeted.

First, a clear distinction must be made between administrative lapses and deliberate violations, with penalties calibrated accordingly. Maintaining strict consequences for sex determination offences is essential but differentiating them from clerical errors would improve both fairness and compliance. According to a NATHEALTH and Arthur D. Little report, 68 percent of cases under the Act relate to clerical errors, while cases involving communication of the sex of the fetus constitute only 15 percent. This highlights the need to focus enforcement more sharply on substantive violations.

Second, a transition from paper-based systems to digital monitoring. Technology-enabled audit trails can strengthen oversight, reduce discretion, and focus regulatory attention on patterns that indicate misuse. A more transparent and standardised digital framework can also simplify compliance without weakening safeguards.

Third, a more nuanced approach to ultrasound usage across specialties. Not all applications carry the same risk profile. Recognising this distinction can help focus enforcement where it is most needed, while enabling broader access to diagnostic services, particularly in underserved areas.

Changing societal norms

The PC-PNDT Act addresses a social challenge that extends beyond the healthcare system. Deep-rooted gender bias and entrenched societal norms that devalue the girl child continue to shape behaviour in ways that no law alone can fully correct. Until these attitudes change, the risk of misuse will persist, and with it, the need for constant vigilance and rigorous enforcement.

At the same time, the manner of enforcement must command trust. The task is not to dilute enforcement, but to refine it, to ensure it remains firm against violations while being proportionate and transparent.

Only such a balanced approach can ensure that the law continues to serve its intended purpose, protecting the girl child while preserving access to essential healthcare.

The writer is a former Health Secretary, Government of India

Published on May 29, 2026