Unsafe abortions are akin to a silent epidemic that claims lives of many women each year in Pakistan
By Farahnaz Zahidi Moazzam
In the heart of the bustling city of Lahore, on Temple Road, is a small clinic, infamous for being one of the quickest ways to get rid of an unwanted pregnancy. This is one of the many such clinics on the street. The clinic’s doors are open to any woman who comes for an abortion. While its staff promises to do the procedure safely and hygienically, its claim to fame is quite the opposite: Horrendous tales of incomplete body parts and remains of aborted foetuses floating past the open drains that run through the area are well-known.
As one enters, they welcome you warmly. A nurse introduces the patient to a lady who “claims” to be the doctor, who is lying on a bench and resting till the next patient strolls in. There is no way of confirming if the woman is a doctor or not. The first question they ask is which residential area the patient has come from. If the patient says she has come from an upscale area, the rates are threefold — Rs12,000 in the first month and Rs25,000 in the second month… and the rates keep escalating depending on how far the pregnancy has progressed.
“It is not my concern whether a patient wants to get it done because she made a mistake with a lover, or wants to abort a female foetus, or uses abortion as a form of family planning, or is healthy enough to carry the child to term or not. My job is to clean out her uterus within hours and send her home. That is all,” says the alleged doctor.
But don’t they know that for an abortion to be legal in Pakistan, the condition is “necessary treatment” which the health provider has to decide? Will they not check the woman’s health status? Her blood counts? And does it matter to them how far the pregnancy has progressed? The questions are dodged. They say they use “the vacuum method and other methods” for abortions.
The clinic is definitely not equipped to handle any post-abortion complication. And this is one of the relatively better clandestine abortion clinics that carry on with their business quite openly.
In another part of Lahore, the situation is bleaker. This is Shahi Mohalla, also known as Heera Mandi. Some 1,500 female sex workers inhabit this area. Contraceptives are not always accepted by their male clients, resulting often in unwanted pregnancies. Already poor, vulnerable to HIV and Sexually Transmitted Diseases (STDs) and exhausted, these women may call for Traditional Birth Attendants (TBAs) or “dais” for deliveries and abortions. But small abortion clinics are a more popular choice.
“Many of them lose the battle of life due to post-abortion complications. The methods used in these abortion clinics of the area are old-fashioned and invasive and often harsh methods that result in complications,” says Lubna Tayyab, founder of the NGO called SHEED (Strengthening Health, Education, Environment, Development) Society that is working for the betterment of sex workers and their children in the area.
Abortions in Pakistan are mostly obtained in clandestine clinics. Very few of these clinics are properly equipped to carry out abortions safely. Providers typically perform dilation and curettage procedures. They almost never used manual vacuum aspiration, a less invasive and safer procedure.
According to a report by National Committee for Maternal and Neonatal Health (NCMNH) and the Guttmacher Institute (Ref: http://www.guttmacher.org/pubs/IB_Abortion-in-Pakistan.pdf), a nationwide study estimated that 890,000 induced abortions took place in Pakistan in the year 2002. This amounts to 29 abortions per 1,000 women of reproductive age. Of every 100 pregnancies, 14 ended in induced abortion.
Deaths, long-term disabilities, health complications and a messed up reproductive system — these are just some of the side effects of an unsafe abortion. Complications can be incomplete abortion, hemorrhage or excessive bleeding, trauma to the reproductive tract or adjacent anatomical areas, sepsis (bacterial infection) and a combination of these complications. Excessive bleeding may have life-threatening consequences, such as anemia or shock. Perforations and lacerations may occur to the vagina, cervix or uterus and may involve injury to adjacent areas, such as the intestines, requiring surgery with full anesthesia. Hysterectomy (removal of the uterus) may be required, leaving the woman permanently infertile. If not treated in time, sepsis can lead to peritonitis (inflammation of the abdominal lining), septicemia (blood poisoning), kidney failure and septic shock, all of which can be life-threatening.
Unsafe abortions are carried out by methods that are a health nightmare. Gulping down large doses of drugs, inserting a sharp object into the uterus, drinking or flushing the reproductive tract with caustic liquids, vigorous movements like jumping or physical abuse, and repeated blows to the stomach are some of them. Incidences have been reported where bowels of the patient are pulled out by mistake, through the reproductive tract.
According to Population Reference Bureau, Women of our World, (2005), the lifetime chances of a Pakistani woman of dying from maternal causes is 1 in 31.
A 1999–2001 university hospital study found that 11 per cent of maternal deaths that occurred in the hospital during this period were caused by complications resulting from unsafe abortion.
However, reliable data on induced abortion is almost impossible to obtain. For something that is done so commonly, it is surprising how well it is hidden. While the evidence is limited, it is clear that post-abortion complications account for a substantial proportion of maternal deaths in Pakistan.
In 1990, the Pakistan government revised the colonial-era Penal Code of 1860 with respect to abortion. Under the 1990 revision, the conditions for legal abortion depend on the developmental stage of the foetus — that is, whether the foetus’s organs are formed or not.
Islamic scholars have usually considered the foetus’s organs to be formed by the fourth month of gestation. Before formation of the organs, abortions are permitted to save the woman’s life or in order to provide “necessary treatment.” After organs are formed, abortions are permitted only to save the woman’s life. (Ref: United Nations Population Division, Abortion Policies: A Global Review, New York: United Nations, 2002). However, generally, this is a debatable issue.
Since 1997, under certain circumstances, abortion is legal in Pakistan, not only to save the woman’s life but also to provide “necessary treatment”.
Most women who have induced abortions in Pakistan are married and already have more children than the average Pakistani woman wants. Thus, abortion is used as a form of family planning.
The average age of the women seeking abortions, reported in several studies, was just under 30. Research provided by NCMNH shows that 96.1 per cent of the women who seek abortions in Pakistan are married. “This shows that it is a misconception that abortions are common in unmarried girls who want to abort an illegitimate child,” says Dr Azra Ahsan of NCMNH.
“Also, female infanticide is not a problem in Pakistan, apart from isolated incidences. In 15 years of medical practice in Pakistan, I have not received a single request for termination of pregnancy on the basis of gender,” says Dr Sadia Ahsan Pal, also of the NCMNH.
Pakistan Demographic and Health Survey 2007 (PDHS) reveals that 41 per cent of urban married women of Pakistan use contraception, compared with 24 per cent in rural areas, while 25 per cent of Pakistan’s married women have an unmet need for family planning, both for spacing and limiting the number of children. This has a direct bearing on the probability of abortions, which is used as a form of family planning.
Unsafe abortions are a public health issue that needs immediate attention. Timely family planning and awareness about use of contraceptives can be the actual solution to this silent epidemic that claims many lives of women each year in Pakistan.
Older than her years
“I belong to district Lodhran in the Punjab. My father got me married off to my paternal cousin when I was 14 years old. My husband is older to me by some 13 years,” says 23-year old-Sughra, who looks much older than her years. She is a mother of two children.
Dark circles, breathless upon walking, dragging her feet, Sughra is displays the classic signs of anemia.
“A couple of years ago my husband beat me up so severely that I could not even swallow or lift my hand for days. I came to my mother’s house. At that time I was pregnant. I stayed on in my parents’ home and thought about ending the marriage. Having another child in such a marriage seemed like a bad idea. I was hurt, and took my revenge by deciding to abort the baby,” shares Sughra, wiping her eyes with a worn out dupatta.
“My mother took me to this daai who charged us Rs 1000. Her instruments were not clean. I still remember the rusty looking, stained metal probes she used. But what option did I have? I was about four months pregnant when I got it done. The daai had promised I would be on my feet the next day. But I was on bed for two weeks, bleeding profusely,” she recollects.
Sughra was finally taken to the nearest hospital where she ended up getting blood transfusions. “My health has never been the same ever since. The doctors said I could have died because of the bleeding and infection related to my abortion,” she says.
Sughra is now back in her husband’s home. He refuses to use any contraceptives, but Sughra now has started using injectable contraceptives. Her face, though, saddens every time she remembers that abortion.