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Reproductive health: ‘Healthy mothers mean a healthy nation’

Published: September 12, 2014

Research shows that when a mother dies, the children that are left behind are more likely to grow into adults with psychological issues. PHOTO: SHIRKATGAH

KARACHI: If you ask me what the government is doing about maternal and reproductive health of women and family planning, my answer will be ‘nothing’, said Planning Commission of Pakistan population section chief Shahzad Malik.

Malik – along with members of provincial assemblies, government officials, gender activists and members of civil society – said this at an event held at the Beach Luxury hotel on Wednesday. Organised by the Shirkatgah Women’s Resource Centre, ‘Next Steps: Achieving universal access to sexual and reproductive health and rights through a coherent post-2015 framework’ was a national consultation with stakeholders.

The discourse remains relevant as ever, with an estimated 30,000 women dying every year due to birth-related mishaps. While Maternal Mortality Rate (MMR) in Pakistan may have improved – dropping from 490 in 1990 to 260 in 2010 – a lot still needs to be done. MMR is the number of women per 100,000 live births who die of pregnancy and childbirth related complications. A staggering number of abortions – somewhere between 800,000 and 900,000 – are carried out in Pakistan every year, and most of them classified as unsafe abortions. Lack of contraceptive facilities and absence of timely family planning are the major reasons, as most women getting abortions are married women getting rid of an unwanted pregnancy.

Representatives from each province shared their experiences and problems. Balochistan’s representation was sorely missing as the speakers could not make it to the event. However, some jarring issues came to the fore in the discussions, such as the fact pointed out by moderator Imran Shirvanee. “Only two political parties bothered to talk to health experts when designing the public health manifesto, before the 2013 general elections,” said Shirvanee, refusing to divulge the names of the parties.

Punjab MPA Dr Najma Afzal Khan shared information about positive reproductive health initiatives and headways made in the province of Punjab. “The Punjab chief minister is committed to improving maternal health,” she said.

“In Punjab, there has definitely been progress,” said Dr Zafar Ikram, provincial coordinator of the Maternal, Neo-natal and Child Health Programme, Punjab. “However, problems such as unmet need of family planning methods persist. Gestational diabetes is on the rise and there is hardly any emphasis on post-menopausal cancer.”

The problems in Khyber-Pakhtunkhwa (KP), as pointed out by MPA Arshad Umerzai, are mostly to do with the security situation. “Also, while the policies of the provincial government in KP may be commendable, a lack of coordination and strained relations between the federal and provincial governments hinders progress.”

Issues related to governance and social and demographic dynamics were also discussed, and recommendations were made to improve the situation. Some of the problems pertaining to funding owe to the confusion that still exists between provincial and the federal governments after the 18th Amendment.

As the participants pointed out, it is time for maternal health to be taken seriously, especially since research shows that when a mother dies, the children that are left behind are more likely to grow into adults with psychological issues. Such issues, experts shared, are likely to fall into extremist behaviour as well.

Published in The Express Tribune, September 12th, 2014.

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I killed my unborn baby because I have too many

39 minutes ago

The conditions under which these abortions are carried out are horrendous. PHOTO: REUTERS

She had no remorse on her face as she sat in front of me sharing the story of her third induced abortion she had gotten done a few weeks earlier.

 “I already have five children. I am working for your mother in Karachi. My family is in a village near Rajanpur. Who’d look after the baby?” said Sughra, my mother’s maid, when I asked her why she kept having abortions.

“In my village, it’s a done thing baji. Every woman gets it done. All married women. The daai (midwife) takes Rs 300. She uses dawaai (medicines) or any sharp instrument. I nearly died in the second one, I bled so much,” she shared the details as I looked on in horror.

I had my first detailed one-on-one meeting with Sughra amongst the one million Pakistani women who have unsafe abortions every year. Over the years, as a journalist working on maternal health issues, I have met scores. The stories have multiplied. The commonalities are many. And it sends shivers down my spine every time. These women are lucky to be alive to tell their stories. Others are not so fortunate. The conditions under which these abortions are carried out are horrendous. They ingest chemicals. They jump and skip ropes. They let unskilled hands plunder their most sensitive organs. They often bleed uncontrollably. They develop complications that often lead to near fatal problems.

Out of the 30,000 maternal deaths yearly in Pakistan, a substantial part is related to unsafe abortions. Yet, it goes on. In shady places. At homes. In small so-called clinics.

Breaking many stereo-types, Sughra taught me a lot that day. For starters, mostly unsafe abortions are used as a form of contraception. Instead of a precautionary method, they think of getting rid of the foetus once it has been conceived. Ironically, many feel it is against religion to practice contraception, but go ahead with an abortion which is strongly discouraged in most religions, while temporary contraception is not prohibited. Other reasons for avoiding timely Family Planning (FP) are husbands refusing to use condoms, myths about contraceptive pills and other forms of contraception, a lack of awareness or simple laziness.

Needless to say, after visiting some of the small abortion clinics, my research left me quite worried. The unhygienic surroundings, the very obviously untrained women posing to be doctors or nurses, and the sheer number of patients are cause for concern. I have walked into such clinics, with the natural advantage of being a woman, and quietly observed what goes on, without having to lie that I am a patient. All this goes on openly. It is known. But not much is done about it.

And this happens across the board, though 96.1 % of the women getting induced abortions in Pakistan are married. The list includes unwed mothers-to-be, commercial sex workers, rape victims and victims of incest. Inevitably, it is the woman’s body that suffers and her soul.

There has to be a solution to this insanity, I always think, frustrated, every time I meet such a woman, or the family of a woman who lost her life or developed a lifetime debilitation. Little Sajid, five-years-old, had lost his mother to an induced abortion in a village in the Bhit Shah vicinity. If only she had practiced contraception in time, Sajid would not be motherless; I thought as I looked at his pale face that had deprivation scribbled all over it.

The answer lies in awareness at many levels. People need to be sensitised to the fact that religion does not prohibit temporary contraception, which includes most forms. Those forms of FP need to be talked about. An example would be the cycle bead rosary which has worked in many developing countries – a simple rosary like string of 28 beads that allows a woman to calculate her fertile days. The shame associated with talking about contraception even within married couples has to be tackled. The mutual decision of birth spacing should be taken by the couple, not the mother-in-law as happens in a lot of families. For this, the men of Pakistan will have to be brought on board.

A holistic solution includes training midwives and traditional birth attendants to perform procedures hygienically, guide families about FP and refer them to the nearest health facility in case of complication.

But to me, the central piece of the puzzle lies in the women prioritising their own health, especially in their child bearing years, and making very careful choices when it comes to their reproductive health. The woman of Pakistan needs to know that she is the most important person in her life, and live her life that way. Only then can she be the backbone of her family.

 

http://blogs.tribune.com.pk/story/17936/i-killed-my-unborn-baby-because-i-have-too-many/

Unsafe abortions: Risky business

Published: June 25, 2013

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Nearly a million Pakistani women resort to abortions annually due to absence of timely contraception. PHOTO: FILE

Nearly a million Pakistani women resort to abortions annually due to absence of timely contraception. PHOTO: FILEA view of a shady clinic located in Lahore. PHOTO: SARAH MUNIR/EXPRESS

LAHORE: The beads of the tasbeeh in her hand are beginning to move faster. She wipes off sweat from her forehead with her lawn dupatta, due to anxiety and the intense 48 degree heat of Lahore, with load-shedding in its 5th hour in a house in Safanwala Chowk.

The dark magenta bedspread seems to intensify the heat in this bedroom on the second floor that serves as a makeshift waiting room for families of “patients”. What is allegedly an “operation theatre” is a tiny claustrophobic room constructed on the roof.

“It’s been almost an hour. Safaai normally doesn’t take so long,” says the worried middle-aged mother, looking out of the semi ajar window overlooking a lane off Temple Road. Her 27-year-old daughter is a mother of five, getting an abortion done. The infamous abortion clinics of this area still exist, but most have been relocated into lanes to avoid attention of the media and health officials concerned. It was after an hour of asking around and driving in the area that a shopkeeper in a secretive manner guided The Express Tribune team in. Immediately, a female gatekeeper locked the gate from inside. “We don’t want anyone to know this is a clinic,” said the over-worked woman who introduced herself as a doctor, but had no degree, certificate or anything that confirmed that she is a medical doctor. The clinics of this area have had thousands of abortions take place in them, some as late as in the 5th month; while the clinicians advise against abortions at an advanced stage, they oblige for some extra money.

Tales of Horror

Timely FP could save lives of not just the unborn foetuses but a multitude of Pakistani women. A national survey of public-sector health facilities estimated that about 200,000 women were hospitalised in 2002 alone for abortion-related complications. “We get cases of perforated uterus, guts, intra-abdominal complications, all complications of unsafe abortions,” says Dr Nadeem Khalid of Family Health Hospital, Lahore.

The methods used are unthinkable. Ingesting 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. Incidents have been reported where bowels of the patient are pulled out by mistake through the reproductive tract.

If the woman survives, she can suffer from long-term disabilities and infertility. Incomplete abortion, hemorrhage, trauma to the reproductive tract or adjacent organs and sepsis (bacterial infection) are common. Post-abortion complications, experts say, account for a substantial proportion of maternal deaths in Pakistan.

Numbers and reasons

Out of the 2.4 million unwanted pregnancies in Pakistan in 2002, some 900,000 were terminated by induced abortions (Studies in Family Planning 2007). The actual number is definitely higher, considering the unaccounted for cases. In a country where only an estimated 30 percent women use contraceptives (NIPS study: 2006-2008), induced abortion is used as a form of contraception. Contrary to popular belief that most abortions are the last resort of promiscuous women, a Population Council study shows that a staggering 96.1 percent of the women who get abortions done are married women.

The abortion rates in the more urban provinces of Punjab and Sindh are substantially lower than those in the Khyber-Pakhtunkhwa and Balochistan. In urban areas, the contraception rates are higher.

The reason why shady clinics and unskilled women end up performing these abortions are two, the main one being simple economics. A doctor in a lower income area would charge an average of Rs2,600, whereas a traditional birth attendant (TBA) would charge as less as Rs770, says a study by Marie Stopes Society, 2008.

Secondly, most certified medical practitioners avoid performing an abortion not just because of religious reasons, but also because they are afraid of legal complications. Under the 1990 revision in Pakistan’s Penal Code with respect to abortions, the conditions for legal abortion depend on the developmental stage of the foetus. Since 1997, under certain circumstances, abortion is conditionally legal in Pakistan to provide “necessary treatment”.

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Women seeking induced abortion

– Highest in age group (30-34) yrs 39.6 % and lowest in (15-19 yrs) 3.9%

– Higher in married women (96.1%) and for single women    (3.9%)

– Highest in women with no education    (62.5%)

– Highest in people with already 5 or more children   (68.2%)

(Source: Population Council) 

http://tribune.com.pk/story/567963/unsafe-abortions-risky-business/

 

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Unsafe abortions – The Silent Epidemic

http://jang.com.pk/thenews/nov2011-weekly/nos-06-11-2011/enc.htm#1


Life sentence 
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.

— FZM