We would like to bring your attention to a specific problem because of which has stalled our progress in normalizing Child sex ratio in our country. This is regarding a specific provision in Pre-Conception and Pre-Natal Diagnostic Techniques Act, 1994 (PCPNDT Act) which disallows efficient modes of communication and relies on age old methods.

Although the intent of the Act is benevolent and intended outcome favourable, the method of implementation has outlived its utility owing to development of more efficient methods of communication and data transfer. If we analyse the rules made under the Act, PCPNDT Act 1994, Rules 2006, Rule-9(7) stands out, which clearly disallows online submission of the documents with regard to this Act. The rule states:

In case the Genetic Counselling Centre or Genetic laboratory of Genetic Clinic, Ultrasound clinic or Imaging Centre maintains records on computer or other electronic equipment a printed copy of the record shall be taken and preserved after authentication by a person responsible for such record.

It is thus a legal mandate to submit PCPNDT Form F along with ultrasound report, ultrasound images, gynaecologist’s OPD consultation sheet and identification documents of each patient as a ‘physical printed hard copy’ (PCPNDT Act 1994, Rules 2006, Rule-9(7)) duly signed by a radiologist/sinologist.

There are about 35000 sonography centres with average of about 2000-5000 antenatal cases served by each centre annually. Thus, a total of about 10-15 Crore antenatal cases are seen every year. Each ‘complete’ form is about 5-10 pages long along with attached documents. Three copies of each report are required for compliance with the Act. Apart from one copy given to the patient, one copy is sent to Appropriate authority and one is kept by the hospital/ diagnostic center and is to be preserved for 2 years as per the law (PCPNDT Rule 9(6)).

Further, keeping a photocopy of ID proof without authentication of identity number (for example Aadhar Number) for name and address puts all the stakeholders in a fix as those giving misleading information and doctored ID cards cannot be tracked and leave a hole in the implementation of the statute.

The PNDT Act 1994 is pious in its intent and purpose. But is it really fulfilling the purpose? Have the draconian provisions of the act served to improve the Child sex ratio? Although the statute has created fears in healthcare community regarding sex determination (and rightly so), its role in reducing female feticide is debatable as the Child sex ratio has actually fallen from 934 (in 2001) to 918 (in 2011) female children for every 1000 male children in the 0-6 year age group (2021 census data not yet publically available).

Going forward in this manner, twenty-five years after the rules were first framed, has a lot of adverse implications on all stakeholders. These are outline below.

1. Government: The govt. falls short of its goals of ‘efficiently’ tracking pregnant patients from conception to delivery in using paper based reporting system.
2. Pregnant females: It is a true fact that almost all patients have aadhar card and have their aadhar number. But most female patients donot carry their aadhar card to the hospital. As a result of this, it creates hassle for such patients that they have to go back to get their cards to get scan done. In rural areas it can result in loss of a day’s wage. Moreover, patients often lose their paper-based previous reports of current or last pregnancy, which can very well provide relevant clinical data that can be important for current pregnancy. Most doctors have to rely on minimal clinical data provided by patients in order to give their opinion. If this data can be made available, we can significantly improve pregnancy outcomes of our patients.
3. Environment: Using papers for recordkeeping which can well be done by a hard drive/ cloud server is an inexplicable wastage of natural resources. Millions of trees would be saved if we switch to cloud based data storage. Valuable hospital spaces which can be used for patient care are held hostage to piles of such records.
4. Radiologists, Gynecologists and Sonologists: The Act has extremely stringent provisions if any of its sections is violated. Contravention of any of its provisions invokes an imprisonment for 3 years plus prohibition to practice for at least 5 years for a doctor (section 23). It is a cognizable, non-bailable, non-compoundable offence (section 27). A government officer is immune from prosecution for anything done in pursuance of the provisions of this Act (section 31). The government agencies are regularly conducting raids using decoy dummy pregnant females and enticing doctors with huge compensation for sex determination in an orchestrated plan to catch them red-handed (Report here). Even minor irregularities in filling of such forms or in maintaining records invoke heavy penalty on innocent radiologists who are busy dealing with their patients, leads to imprisonment (Report here). As a result of clerical error many doctors are facing jail penalty while they could be spending their time serving the society. Government agencies are not wrong in identifying and going against such doctors as they are following the provisions of law. However, both of them could be saved from such hassles if procedure is amended to suits the needs of the day and make the statute work more efficiently for its intended purpose. It is of utmost concern that due to the stringent provisions of PNDT ACT, many MBBS graduates are now preferring branches other than Radiology and Gynecology. Moreover, those already practicing these specialties are now scared of private practice and thus prefer ‘safe reporting’ and focus more on forms and ‘procedural compliance’ than core reporting. It is my biggest concern that we must not lose such brilliant minds in healthcare to other professions due to fear of penalisation because of procedural irregularities.

PROPOSAL

When we already have a solution, then why are we reluctant to move ahead? The proposal is to turn the whole process of form F submission digital. This will prevent any errors in filling of form and maintenance of records.

Although a few states such as Rajasthan, Delhi, Odisha etc have made efforts to foray into digital submission of form F, it is at a miniscule scale and does not help improve efficiencies as the forms, even if filled online, still need to be printed and submitted every 5th of next month and a copy of record kept for 2 years. In conclusion, still a lot of work needs to be done to reduce redundancies and enhance efficiencies.

In order to substantively improve the system, we propose following procedure for form-F submission:

1. All requests for ultrasound by gynaecologists for obstetric ultrasound to be registered online on a central registry.
2. The patient details to be authenticated using aadhar based authentication.
3. Various fields of Form F to be filled online. Critical fields of the form to have validation to reduce chances of error and omission.
4. Ultrasound can only begin after a unique number is generated which shall be punched into the ultrasound machine before the ultrasound scan can begin.
5. Images from Ultrasound machine can be fetched and attached to patient record.
6. Ultrasound report is already printed using a computer. The Form F related relevant findings can be fetched from the ultrasound report and filled in the form automatically. Report Templates can be made and form F integrated into the report.
7. Doctors to digitally sign the documents ensuring authenticity of records. Authentication of Gynecologists, Radiologists and Sonologists can be done using secure methods thus preventing impersonation.
8. Real time submission of Form F along with attached ultrasound request, ultrasound report, aadhar authenticated patient address and other relevant details can be sent to a central agency (and/or to the District appropriate authority), for data compilation and pregnancy tracking.
9. The govt will thus have all the relevant data regarding status of pregnancy, doctors who are involved in care of a patient, past demographic data of the patient and all other details necessary to track the patient along with her medical records.

What are the benefits of proposed process (online digital submission of PCPNDT Form F):

1. Reliable data: This process will ensure that the government has ‘reliable and authenticated data’ on female patients and doctors involved in antenatal care of every patient.
2. Faster data processing: It is a fact that digital form of data can be processed and analysed easily. Such a data can be sorted and moulded in different ways to suit the need of healthcare authorities such as focussing on specific areas with low female sex ratios, tracking every pregnancy till delivery and immunization, implementation of social security schemes for female new-borns, channelization of subsidies for delivery and healthcare.
3. Eliminate human errors: Online submission will streamline the process of form F submission. This will ensure all forms are duly filled and submitted. Elimination of manual entry will prevent human errors in filling forms at the doctor’s end and in data entry at government’s end. This will help in reducing a number of undue cases registered against doctors for procedural irregularity in filling forms.
4. Release Record Rooms: Online storage will release workspaces occupied by tens of billions of PCPNDT forms, which can well be utilized for patient care.
5. Better resource management: This system will help govt. save crores of rupees spent on implementation of the Act.
6. Save environment: As a bonus, hundreds of crores of papers and millions of trees shall be saved every year.
7. Better pregnancy outcomes: Having past pregnancy records and past ultrasound records of current pregnancy is known to deliver better outcomes.

With the advent of internet and advancement of software technology online authentication and communication is not difficult at all. All of us do it every day. The internet infrastructure and cloud storage technology has brought about a revolution in almost every sector. Even the most sensitive of all the communications such as banking transactions and income tax filings are done online. Therefore, there must not be a security concern.

Finally, it is our moral responsibility to evolve systems and processes with time and make them more efficient. In order to ensure that every girl child is born into this world, we need to ensure that our doctors practice fearlessly and take responsibility of their actions. Laws are enacted for the benefit of people and laws evolve with time. All the stakeholders- doctors, government and civil society- must now make a concerted effort to ensure that while preserving its pious intent our laws adapt to changing times and do not become a hindrance to our growth and sustainability.

In this regard, we propose amendment of PCPNDT Rules2006, Rule 9(7) as following:

“In case the…. ultrasound clinic or Imaging centre maintains a record on computer or other electronic equipment in a manner authorised by and in accordance with the procedure laid down by the government, a printed copy of the record shall not be required to be preserved for the purpose of the Act”

If we do not act now, our future generation of doctors, healthcare champions, pregnant mothers, government office bearers and especially our children will never ever forgive us. The time to act is now, right now.