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28 Sep 17

Montenegro’s Open Secret: Illegal Gender-Tests for Unborns

 

Genetic testing to find out the sex of an unborn baby is illegal in Montenegro, but it is not unusual in a society that values boys over girls - and for clinics, it’s a profitable business.

Svetlana Slavujevic BIRN Podgorica
 
 Amela, a 43-year-old mother of three in Bijelo Polje, in northern Montenegro

“If it had been a girl, I don’t know what I would have done,” says Amela as she recalls waiting to find out the sex of her unborn baby.

Ten years ago, Amela, who is now a 43-year-old mother of three in Bijelo Polje, in northern Montenegro, was hoping for her first son.

Keen to know if she really was carrying a boy and not another girl, Amela took the road that many women from Montenegro follow.

In the first weeks of her pregnancy, she went to the Serbian capital Belgrade to take a genetic test at a private clinic to determine the baby’s sex.

“Luckily, it was a son. I wanted a son to please my husband,” she says.

Giving birth to a son to avoid criticism and even condemnation from both family and society is an obligation that many women in Montenegro have faced for centuries.

“I know women who had several abortions after the chorionic villus sampling [CVS] test, having learned they were carrying a girl,” says Amela.

While in ancient times, women tended to resort to fortune-tellers, now they look to genetic medicine for a sign.

Away from the public gaze, some gynecologists in Montenegro are addressing this need in league with private clinics in Serbia.

Women undergo a painful CVS test so they can learn the sex of their child before the expiry of the legal deadline for an abortion, which is ten weeks in Montenegro.

The average price of the procedure is about 350 euros.

The law in both Serbia and Montenegro bans genetic testing to learn a baby’s sex.

In Montenegro, such tests are only allowed if serious genetic disorders are suspected and may only be done at the Clinical Centre in Podgorica, which is why many women travel to Belgrade to have the tests done.

The women who were interviewed for this article by BIRN and CIN-CG did not want to give their own names, or name their gynecologists, or the clinics in Belgrade where the doctors did the genetic tests.

An informal code of silence is upheld by the women, who do not want anyone to know what they did, and the doctors, who prefer their activities to remain unpublicised.

But despite this, there is no doubt that genetic tests are easily available.

When the author of this article, posing as a pregnant woman from Montenegro, called three private clinics in Belgrade and asked about taking a test to learn her baby’s sex, all invited her to “come on in, and everything will work out”.

As well as taking the CVS tests in Belgrade, some women are also resorting to the Nifty test, which allows them to learn their baby’s sex from a blood test.

However, the results of the Nifty test are only accurate if it is done at the 12th week of pregnancy – which is two weeks after the legal deadline for an abortion expires.

Some private gynecologists in Montenegro are ready to perform illegal abortions at this point, according to sources, some of whom wanted to remain anonymous.

The genetic tests to learn a baby’s sex may be illegal and pricey, but it appears that they are yielding results in terms of a higher birthrate of male children.

Over the past 20 years, 109 boys to every 100 girls have been born each year on average, according to the Statistics Institute of Montenegro, Monstat.

Only sons count

Asked how many children they have, older men in socially conservative northern Montenegro still often only talk about their sons. Daughters are not taken into account.
Ranka Bozovic, a psychologist, explains that in Montenegro, the birth of a male child was traditionally a cause for celebration.

This is because a son is an heir who will extend the life of the family name, protect the home and defend the country in times of war.

“A husband certainly expects a son and when a woman does not give birth to a male child, she is less worthy, and so, in time, he may start to belittle, even torture her,” Bozovic says.

She herself witnessed the post-birth trauma of a woman with whom she shared a room who had just given birth to a daughter.

“She did not want to breastfeed her, though the baby was lying by her feet, because she was… her fourth girl.”
 

In 2010, 113 boys were born for every 100 girls. The natural proportion is closer to 102-103 boys per 100 girls.

According to UN Population Fund data from 2012, Montenegro is near the top of the list of countries with the sharpest imbalance between male and female newborns in the world. It shares this distinction with Albania, Azerbaijan and Armenia.

Montenegrin MPs have tried to deal with this problem by passing several laws to regulate the use of genetic science to detect a child’s sex, as well as limiting abortion.

A report entitled ‘Protect Girls from Sex-Selective Abortion’, by the American Population Research Institute, which covers the period from 2000 to 2014, estimates that 50 female babies are aborted for this reason each year in Montenegro. This figure comes from a comparison of the actual number of girls born with the expected number.

The exact number of sex-selective abortions in Montenegro remains unknown, however, and the informal code of silence means that there are no reports about women terminating pregnancies after getting the results of genetic tests.

In Podgorica and Belgrade, doctors collaborate

Amela had already given birth to two daughters when she decided to make sure that this time, she would be carrying a boy.

Before she got pregnant for the third time, she visited her gynecologist to agree what she should do.

“I already heard from the women around me that a bunch of them were going to Belgrade to get the CVS done. My doctor told me not to worry and to come back when I was pregnant and we would arrange everything,” she recalls.

 Amela, a 43-year-old mother of three in Bijelo Polje, in northern Montenegro

The CVS test involves a chorion biopsy, during which a sample of the placenta is taken. Results are obtained in a few days, leaving women time to spare to have an abortion before the legal deadline expires.

Amela was eight weeks pregnant when her gynecologist in Montenegro scheduled the procedure at a private clinic in Belgrade.

“Many women I met in the [gynecologist’s] waiting room were there to get advice on how to get a son, and he was scheduling tests for them in Belgrade,” Amela says.

In Berane, in the north of Montenegro, Dr Svetlana Balac confirms that women often seek her advice about prodecures which will help them to “get a son” because they are considered less worthy if they have only girls.

Some face threats or punishment if they cannot produce a boy.

 Dr Svetlana Balac from the town of Berane, in the north of Montenegro

Balac recalls one woman from Rozaja whose husband told her that if she did not give him a son, he would divorce her.

She explains that when a woman comes to her clinic, she usually knows what procedure she is looking for.

“She more or less knows what she wants and the doctors are simply there to resolve some of her uncertainties,” she says.

“In that case, I can only [help] with advice, to explain where [to do it] it, how [to do] it,” she adds.

What the law says

Montenegro’s Law on Protection of Genetic Information says genetic testing of a foetus may be done for medical reasons but only on the advice of a doctor from a specialised genetics clinic.

The law governing the treatment of infertility prohibits selecting the sex of the fertilising cells and says the selection must be random.

A third law prescribes when a pregnancy may be terminated for non-medical and medical reasons.

An abortion may be done up to the tenth week of pregnancy on the request of the pregnant woman and with the approval of a gynaecology and obstetrics specialist.

Abortion remains possible up the 20th week based on an opinion of a special committee of a health institution.

Termination may be approved also if this is to prevent adverse effects on the life and health of the woman, or to prevent the birth of a child with psychological and physical deficiencies.

It may also take place if conception is the result of a criminal act, or if the woman will face particular socio-economic and family hardship after giving birth.

Between the 20th and 32nd weeks, termination is allowed only based on medical indications and with the approval of the Ethics Committee of the Clinical Centre of Montenegro.

An abortion cannot be done in any circumstances after the 32nd week of pregnancy.
 

Dr Dusan Protic, who owns a private gynaecological practice in Belgrade, says that compared to other countries in the region, the majority of his clinic’s female patients come from Montenegro.

“Many women hide why they are coming. They are looking for a CVS but they always invent a story, such as there being some anomalies in the family. Mostly, when they hear [that the baby is a girl], they ask for an abortion,” Protic says.

“In the hospitals, when they want to abort, when they don’t like the sex [of the unborn child], they cite social and economic reasons,” he adds.

Protic insists that there is a risk of damaging the foetus if a CVS test is performed early, in the eighth or ninth week of pregnancy.

Meanwhile Amela says that she now regrets doing the test because her son had serious health problems after he was born, which she blames on the invasive procedure.

Medical ethics put to the test

Ivana, who lives in the Montenegrin capital Podgorica, also journeyed to Belgrade for a CVS test.

Now 45, she is the mother of two adult daughters. She says she underwent the CVS ten years ago, at an early stage of her pregnancy, because she feared that her baby might be born with a genetic disorder.

She says her gynecologist advised her to go to a clinic in Belgrade, “where they will quickly take care of everything, because the doctor from that hospital often comes to Podgorica”.

She remembers arriving in the waiting room of the clinic and finding it full of other women from Montenegro. She and her husband signed a waiver in case something unforeseen happened.

She also remembers the hook-shaped needle that the gynecologist inserted into her stomach next to her belly button.

“To this day, I shiver when I remember the sampling process and the ripping pain,” she said.

“I watched the entire procedure on a large screen. But what is engraved on my memory is the doctor saying with a laugh: ‘We know why you Montenegrin women come here.’”

 Dr Svetlana Balac from the town of Berane, in the north of Montenegro

She said the test showed she had an 87 per cent chance of her baby having a genetic anomaly. It was also a girl.

She had an abortion on returning to Podgorica.

None of the three private clinics in Belgrade contacted by BIRN and CIN CG for this article in June and September asked for referrals from doctors in Montenegro indicating suspicions of a genetic anomaly. No previous tests were deemed necessary before the clients arrived.

BIRN and CIN CG has not named these private clinics because it was not possible to prove that they did carry out tests to determine a baby’s sex.

Professor Olivera Miljanovic, director of the Centre for Medical Immunology at the Clinical Centre of Montenegro, says that genetic testing is a risky area that is open to abuse.

“Genetic research is used solely for medical purposes, when the genetic status of the baby must be determined to confirm the risk of a serious genetic illness. Everything else is abuse,” Miljanovic argues.

Pain-free test misses the deadline

Since 2014, parents in Montenegro have also been able to non-invasive prenatal tests to find out the sex of their babies.

In the 12th week of pregnancy, the foetus’s DNA can be analysed from the mother’s blood.

At least four laboratories and gynecologists’ offices in Montenegro offer such tests, the most popular being the Nifty test.

They send a sample of 10ml of blood to large worldwide-accredited laboratories for analysis. The In Vitro laboratory in Podgorica alone sends about 2,000 blood samples a year, while Bona-Lab Prima sends 700.

Laboratories in Montenegro offer two types of the Nifty test, which differ in terms of the number of parameters they analyse.

One checks for only three syndromes - Down’s, Edwards and Patau.

The more advanced ‘Plus’ version offers a wider analysis, including sex chromosomes, and is precise in determining the baby’s sex. The Nifty Plus test is also more expensive, costing 650 euros.

Bona-Lab Prima told BIRN and CIN CG that “99 per cent of women” using its services want the Nifty Plus.

The lab’s owner, Dragan Nikolic, says the tests were introduced in 2014 and enable mothers to learn whether their foetus is healthy, but are also used by women who are desperate to have a male child.

“We have had requests from women who have two or several daughters and who want a son - and they want to see what sex the baby is,” Nikolic says.

“Few women will say openly, ‘I’d like a boy or a girl.’ It’s up to you, when you ask them how many children they have, to deduce that they most probably want a boy,” he adds.

Authorities powerless to stop selective abortions

No cases of selective abortions have been proven in Montenegro, although the phenomenon clearly exists.

Since they often learn the sex of their children through genetic testing early on, women can decide to abort the pregnancy if they are carrying a girl, either legally or illegally.

Up to the tenth week, women are not required to state their reasons for wanting an abortion.

That means the number of selective abortions remains hidden in broader data on the total number of abortions recorded by the Public Health Institute of Montenegro.

 Professor Olivera Miljanovic, director of the Centre for Medical Immunology at the Clinical Centre of Montenegro

The law also allows a woman to have an abortion up to the 20th week if she faces the risk of “personal or family hardship during pregnancy or after giving birth”.

However, this needs to be approved by a panel of doctors or special ethics committee.

Birth ratios in Kosovo, Albania, Macedonia

Reports by the Council of Europe and other international organisations have warned for years about an alarming imbalance in the birth ratio of boys and girls in other countries in the Balkans.

According to a 2016 report by the World Economic Forum, a Swiss-based think tank, Albania published worrying statistics about the number of births of male and female children.

The Albanian data for 2016 showed that 109.5 boys were born for every 100 girls.

The situation is similar in Kosovo, where an average of 110 boys are born per 100 girls, according to a report by the UN in Pristina.

The problem is also pronounced in Macedonia. The Marseille-based French Institute for Development reported in May 2015 that 110 boys were born to every 100 girls.

Research by the Council of Europe in 2013 showed an even greater disbalance, with 113 boys born per 100 girls in Macedonia.
 

Visnja Orban, deputy director of the Ministry of Health’s Inspection Administration, says that some women mislead the authorities in order to get a termination approved.

“Patients do the tests, and see that they don’t like the sex and then file a legal request [to abort],” Orban says.

“But to protect themselves … the patients write that they cannot [give birth] because of their social status, or something else, while they are really doing this because of the [child’s] sex,” she adds.

If they want to avoid detailed checks and tests, women can seek illegal abortions from private gynecologists who do not have permits for such procedures, but will keep it a secret.

Montenegro’s Ministry of Health permits only the Clinical Centre of Montenegro, state hospitals in most municipalities and one private clinic, Codra in Podgorica, to carry out abortions.

But two private gynecologists’ offices in Podgorica, contacted in September by the author of this article posing as a pregnant woman, said they could do an abortion, although they are not on the list of offices licensed by the Ministry of Health.

In one of those offices, the author was asked how far along the pregnancy was. When she said that the pregnancy was in week ten, the office said: “Just come in, we will agree on everything.”

Ivana from Podgorica, who took a CVS test in Belgrade and subsequently had a termination, says that she took a friend who was five months’ pregnant to a private clinic in Podgorica for an abortion.

“The price is known. For each extra month [beyond the legal deadline], you pay an additional 100 euros,” she says.

According to the Public Health Institute, the number of legal abortions rose from 1,141 in 2013 to 1,582 in 2015.

Gynecologist Svetlana Balac says she has no doubt that a large number of illegal abortions take place in private gynecologists’ offices.

“If you look at the official statistics, the number of terminated pregnancies is so low that it is shameful to refer to this as data,” she says.

Montenegrin law envisages fines ranging from 500 to 2,000 euros for terminating a pregnancy because of the baby’s sex or for performing genetic testing for sex selection purposes for non-medical reasons.

But Orban says that in the past two years, not one doctor has paid this fine. She says she does not have data for the years before that.

In 2013, after 113 boys were born for every 100 girls that year in Montenegro, the Council of Europe warned the Podgorica authorities to pay more attention to the situation, bearing in mind that Montenegro has signed the Convention on Human Rights and Biomedicine, which aims to prevent the misuse of medical techniques.

Montenegro’s Ministry of Health could offer no explanation for the discrepancy in the number of boys and girls being born, however.

“We do not have any reports of confirmed, established or indicated abuse with reference to some concrete person or concrete health institution,” says Slavojka Sukovic, head of the Directorate for Harmonisation of Regulations and International Cooperation at the ministry.

“Suspicion is not proof,” she adds.

Health inspectors say they are powerless to intervene because they can only do so if a patient files a report, which none of them ever does.

However, based on the suspicions that have been raised, the ministry’s inspectorate has said it will intensify checks on gynecologists’ offices.

In the meantime, a combination of patriarchal tradition and modern medicine seems to be having a damaging impact on Montenegro - the number of women of reproductive age in the country is falling.

According to Professor Miljanovic, the least populated state in the Balkans now has 3,000 fewer women of reproductive age than should be expected.