A private member’s bill sponsored by Independent Victorian Senator John Madigan seeks to remove Medicare funding for abortions “procured on the basis of gender selection”.

Debate on the bill is due to resume this month. Before it does, writes Caroline de Costa in the post below, Senator Madigan – and all of us – should have a much bigger discussion about the implications of non-invasive prenatal testing (NIPT) and think about what’s really needed to prevent sex selection abortion.

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Caroline de Costa writes:

This  month the private member’s bill sponsored by Senator John Madigan, the Health Insurance Amendment (Medicare Funding for Certain Types of Abortion) Bill 2013, is expected to come back to the Senate for debate.  The aim of the bill, according to the Senator, is to prevent Medicare funding for any service related to gender-selective abortion. The Senator fears that couples from ‘certain ethnic groups’ may be obtaining pregnancy terminations in Australia following an ultrasound diagnosis of fetal sex.  These ethnic groups are from specific Asian countries; it is well-known that the practices of abortion of female fetuses, and murder of newborn female infants, occur in these countries with a resultant marked gender imbalance in their populations as a whole.

However according to the June 2013 report of the Finance and Public Administration Legislation Committee, charged with investigating matters surrounding the Bill, no evidence has been found of selective abortion being undertaken in Australia, either generally or in specific groups.

Australia’s sex ratio at birth, of 105.7 males to 100 females, remains stable and in line with that of other developed nations. It is well recognised that a slight preponderance of male infants at birth is a normal and natural phenomenon.

Numerous submissions to the Committee’s inquiry made these points. They also questioned how health professionals would ascertain that abortion was sex selective, in any particular case. Senator Madigan’s advisors appear not to have considered this aspect of his legislation, indeed they do not appear to have thought through any of the practicalities, nor the cost, of his proposal.  And those advisors, as well as the Senator’s supporters who wrote to the inquiry, were apparently aware only of ultrasound scanning as a medium for determining fetal sex, a method which cannot be used until after the first trimester (the first three months of pregnancy), meaning that an abortion cannot be sought until the second trimester. Abortion in the second trimester is more complex, prolonged and risky for the woman than it is in the first weeks of pregnancy.

In fact since 2012 a much simpler and very accurate method of determining fetal sex has been available to Australian women. Non-invasive prenatal testing (NIPT) is a highly reliable test that involves a negligible risk to a pregnant woman, and none at all to her fetus, since all that is required is a sample of maternal blood taken from a vein in the woman’s arm. It was first available through overseas laboratories, with the blood sample for the testing being taken in Australia. Since March this year it has been offered by Australian providers. Offered, that is, to women who can afford it (from $400 upwards). Many can – private obstetricians across Australia report an enthusiastic response from pregnant women.  And the technology is such that it must soon become feasible and cost-effective to introduce it in the public sector.

Work in Hong Kong and elsewhere in the first years of the 2000s has shown that free DNA crossing the developing placenta from the fetus into the mother’s blood can be reliably identified and analysed; rapid developments in DNA-detection technology have made this analysis commercially viable. NIPT is now used with 99 per cent accuracy at 10 weeks of pregnancy to detect trisomy 21 (Down syndrome), and two other major chromosomal abnormalities (triploidies 13 and 18) and for sex determination (whether a feus has two XX chromosomes, a female, or XY, a male).

The latter finding has some medical relevance in certain inherited sex-linked conditions such as haemophilia but there is no doubt that for most Australian couples the testing is already being widely used simply to know as early as possible whether a girl or a boy is expected. While NIPT is still recommended as a screening method not a diagnostic test, its accuracy is not far off that of the very invasive chorionic villous biopsy method of determining fetal chromosomal details or even that of amniocentesis.

There is no suggestion that this testing is not being used responsibly by Australian women and their doctors. On the one hand it greatly assists in diagnosing several severe fetal abnormalities, enabling a couple with such a diagnosis to consider termination much earlier in the pregnancy than was previously the case.  On the other, a majority of Australians have for many years  chosen to know the sex of the fetus at the 18 week ultrasound that is a normal part of antenatal care. This scan is covered entirely by Medicare.

Clearly parents do not subsequently rush out at 18 weeks to embark on termination of pregnancy because they would prefer an infant of the opposite sex, and there is no evidence to suggest they would do so if given this information earlier in the pregnancy. Nevertheless it must be said that there is now the potential for everyone to have sex determination  (and other chromosomal tests) carried out much earlier in pregnancy than three or four years ago. The pregnancy can then, potentially, be terminated more easily, still within the first trimester, than was previously the case, should parents choose to do so.

NIPT is also likely to become more sophisticated, available earlier in pregnancy (it is known that some fetal DNA can be discerned in maternal blood at six weeks of pregnancy) and able to give parents more and more detail about the physical characteristics of their potential offspring.

There is overwhelming support in the Australian community for a woman’s right to choose to terminate a pregnancy (including from this writer). The 2003 Australian Survey of Social Attitudes showed that 81 per cent respondents supported the pro-choice position, 9 per cent were opposed and 10 per cent had no opinion. However submissions to the Committee’s 2013 inquiry demonstrate that many in both pro-choice and anti-choice groups are opposed to sex selective abortion in principle.

Both sides of the argument pointed, rightly, to the disastrous effects of the practice in countries where it is common, as well as to the inherent concept of gender inequality. It is likely that within the 81 per cent of the Australian population supporting a woman’s general right to choose would be a significant number who would not support that right on the grounds of gender alone, and possibly not on the grounds of some other physical characteristics of the fetus.

However preventing sex selection abortion effectively involves education, advocacy, awareness activities, and legal and policy measures that are supportive not prohibitive. Women being offered NIPT should be well informed and have access to expert genetic counselling services. Madigan’s Bill provides for none of this. It should be scrapped, along with the report of the Committee, which is now completely out of date. Instead, the Senate might debate the urgent need for wider community knowledge and discussion about the implications of NIPT, and how to respond to this. Soon.

Caroline de Costa is Professor of Obstetrics and Gynaecology at James Cook University College of Medicine in Cairns

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