April 19, 2012

Ultrasounds and Pregnancy

Dr. Rajendra Kale, who recently ended his position as interim editor of the Canadian Medical Association Journal, has gone out with a bang. He wrote an editorial urging that women should not be told the sex of a fetus before 30 weeks into pregnancy. This policy was proposed to avoid women choosing to abort a female fetus, as abortion after 30 weeks is much trickier.

This preference for male babies has caused serious gender imbalance in places like China and India, leaving males with an inability to find a mate.  An economic analysis would suggest that the imbalance should increase women’s status, due to their shortage.  Not so.  One thing that has been happening is that wives in rural China are being kidnapped and spirited away to distant locations and united there with a man seeking a partner.

Kale is concerned about the matter in Canada because some Chinese, Hindu, and Sikh women are also resorting to the abortion of female fetuses.  The evidence is in the differing ratios of boys to girls in these communities compared with the ratio in Canada as a whole. 

Several issues arise from Kale’s position: Is his solution to the problem ethical?  Would it be effective?  Are there other ways of addressing the problem?  And are there other implications of the ultrasound debate?  Let’s begin with the ethics.

We can, I think, agree that it would be discriminatory to impose such a policy just on women from certain immigrant groups.  Imposing it on all women raises the principle of the patient’s right to her medical information.  Kale answers that the sex of the fetus is not medical information.  There is also the principle that a woman has the right to have an abortion if she wants one.  That is where the ethical debate sits.  But does the lack of access to information from an ultrasound prior to 30 weeks prevent a woman from learning the sex of her fetus?

To begin, the banning of ultrasound information is hardly airtight.  There are private clinics in Canada.  If these clinics are forbidden to reveal the information, a woman can go to the United States for an ultrasound.  Thus, while the number of sex determinations might be reduced because of cost, they would not be eliminated–except that there are other methods for determining the sex of a fetus.  For example, a blood test can get the information far earlier than 30 weeks.  In short, what Kale recommends would be ineffective.

What, then, might be done to address the problem?  One approach might be an educational program within the immigrant communities, focusing on the consequences of sex selection.  If sex selection is widespread, the males born into the group could have a difficult time finding a mate from the group in Canada.  Some now go abroad to find wives, at times for marriages arranged by their parents.  Parent selection of spouses is declining in Canada due to the influence of the wider Canadian society on young people.  If young men cannot find a woman from their own ethnic and religious group, some will marry out. 

To the extent that people become more fully aware of these implications on their ethnic and religious communities, already under stress from the impact of the wider society, sex selection might decrease.  In any case, to the extent that mate selection takes place resulting in more marriages to women outside the group, we would expect those wives to be less inclined to repeat the pattern of preferential selection of male fetuses.

Let us turn to another issue involved.  Ultrasounds are not necessary in normal pregnancy.  Inappropriate ultrasounds constitute an expensive burden on the medical system, and it is generally agreed by experts in the field that ultrasounds are greatly overused.  They should be used only when medically indicated, and their use by doctors should be monitored and curtailed.

Finally, while research as to the effects of ultrasound on offspring is only very sketchy at this point, and while most of the research has been reassuring, one pattern has emerged that suggests that there are impacts on the brain.  Children who as fetuses received ultrasounds are significantly more likely to be left-handed.  We don’t know what else might be happening.