June Issue 2015
Whose Baby is it Anyway?
The statistics are appalling, and they’ve virtually doubled over the past 10 years. Each year adds to the country’s ever-burgeoning statistics for illness and death – many of the latter entirely preventable. With a steadily growing population and healthcare facilities and population planning projects unable to keep pace, this has long been a crisis waiting to happen.
A case in point: abortion. According to a study by the Population Council, about 2.25 million abortions take place in Pakistan annually; most are clandestine and unsafe, leading to about 2-12 per cent deaths each year. Additionally, 693,000 women suffer post-abortion complications – and these grim numbers do not look likely to change any time soon.
The profile of abortion seekers has remained largely that of poor, 30-plus uneducated women with at least three children, with no means to stop the repeated childbirths they are made to endure in quick succession – sometimes due to contraceptive failure.
Often, the abortions are at the cost of their health, and sometimes their life.
A complicated law, beliefs that stigmatise abortion and ignorance and lack of awareness, have led countless women to endlessly suffer needless illness and death. The Millenium Development Goals (MDGs) have largely remained just that – unfulfilled goals, particularly in regard to maternal health. And while goals in regard to the eradication of extreme poverty and hunger, the promotion of gender equality and the empowerment of women have seen a few positive outcomes. It was envisaged that women’s mortality due to childbirth would be reduced to 140 per 100,000. This has not happened.
There has been a small reduction in the maternal mortality ratio in Pakistan, from 276 deaths per 100,000 live births, to 260 per 100,000. But women are still paying with illnesses and even their lives because of long-term neglect of their health by the state. The numbers for abortions each year speak for themselves.
Women’s health is affected by several factors, including poverty that affects virtually half the nation, illiteracy, significant gender discrimination (Pakistan ranks an abysmal 115 of the 145 countries on the global Gender Equality Index), the absence of social support programmes, and inadequate outreach to the ones that exist.
Even within poverty-stricken families, there is disproportionate distribution of poverty. The feminisation of poverty has become an all-too-visible phenomenon, with women and children the most affected. The birth of a child, which should be a joyous occasion, becomes fraught with tension: Will it be a boy? With so many mouths to feed, how will the family manage?
The predicament lies in the paucity of family planning facilities and it is crucial to address this failure. Without doing so, women’s fertility rates will continue to remain high, and they will be left with little recourse to plan their families – except by abortion.
The country is presently experiencing what many refer to as a demographic dividend, in that over 60 per cent of the population is below age 30. This would usually be considered a plus point for national growth and development – but only if handled right. If not, with critically needed family planning facilities woefully inadequate, the female half of this youthful population is likely to become prey to abortion statistics.
In Pakistan, most women who seek abortion are married, with three, four or more children each. In most cases, their husbands are supportive of their decision to abort. And yet, the desire for more sons (usually voiced by the husband or mother-in-law) means that couples will go on attempting reproduction, sometimes despite the woman’s ill health.
According to researchers, Pakistan is currently experiencing peak interest in the provision of safe abortion services and treatment for unsafe abortion-related complications. And physicians can play an important role in improving abortion-related services and reforming current laws on abortion. The question is, will they?
A survey of health care providers’ attitudes, their awareness of abortion laws, and their views regarding existing laws on abortion revealed that the majority of health care providers (67.3 per cent) are not in favour of induced abortion, with only 25 per cent favouring it. All healthcare providers were aware of the abortion law in the country and 46.5 per cent did not think that any change was necessary. Telling of local attitudes was the fact that 80.9 per cent of those who wanted the law to be changed said that the existing law was too liberal and this should be made more strict.
It was acknowledged by the medical fraternity surveyed that despite the already restrictive legal status of abortion, large numbers of abortions continue to be carried out. Hence, one would imagine, the ground realities call for the liberalisation of abortion laws. But many doctors demur. And according to some senior doctors, since the liberalisation of laws would not be possible without the support of the ulema (religious scholars) and politicians, they should be apprised of the situation and their advice solicited.
Though the Pakistan Penal Code makes provision for abortion if the life of the mother is endangered, the fact that no data is available concerning legally induced therapeutic abortion indicates a restrictive interpretation of the law by the medical profession. This observation is supported by the fact that there is considerable difference of opinion regarding medical indications for the termination of pregnancy among practicing gynaecologists.
And though some doctors accept that the termination of pregnancy is acceptable if the mother’s life is at risk, a much larger number of doctors decline to carry out any such procedure because of religious or personal beliefs, and what they perceive as the danger of being labelled ‘abortionists.’
As such, women across the country seek health providers, trained or untrained, who will do the needful. Complication rates are high even when women believe that the health provider they have gone to is a safe one, particularly if he/she operates out of a clinic or hospital setting.
Ironically, among the numerous health problems women in Pakistan face, many are easy to treat. Several research studies (including a recent one by Shirkat Gah) indicate that women’s poor health is both a medical problem and a socioeconomic one, deeply related to women’s status.
Without addressing the socioeconomic milieu in which a woman lives, it is not possible to satisfactorily address her health or medical problems. Poverty may constrain her from taking care of her own and her family’s nutrition; water scarcity may be severe in the area where she lives; and she may be in strict purdah with no access to healthcare outside her home. And then there is the stigma attached to abortion. The alleviation of women’s health problems thus requires a concerted multi-pronged approach.
Maryum Siddiqui and Hina Ansari (of Shirkat Gah) are both familiar with work at the grassroots level in socioeconomically depressed communities and they have found an overwhelming stigma in the matter of abortion. This has led to the exclusion of abortion from the normative reproductive health package, leading to the entry of quacks and back-street clinics for accessing services. Hence the high local, maternal morbidity and mortality.
Said Siddiqui, “During our baseline research we found that those who terminate their pregnancy were regarded by the community as lacking in compassion, and a disgrace to society. The community was quick to connect abortion with killing, by justifying that abortion is inherently wrong because according to one of them, God puts the soul in the child in the initial stages of conception – so how can one say that you’re not killing a living, breathing piece of life?”
Not only does the community staunchly believe that abortion is the murder of an innocent child, the respondents of the study conducted to determine mindsets, also firmly believe that no woman would willingly kill her own child, hence if there is an abortion the legitimacy of the infant is questionable. In addition to morality, there are other religious reasons behind the disdain linked to abortion. The common religious belief is that every soul brings his own sustenance with him into this world, and that a child should not be killed for fear of poverty. The act of abortion is considered anti-Islamic and hence a grave sin, and this is a sentiment shared by many professionally trained service providers (SPs) who refuse to offer abortion no matter what the situation.
Miscarriages have also been frequently reported at the grassroots level, due to various factors such as weakness, malnutrition, work overload, minimal birth spacing and early marriages. Ironically, the SPs who disapprove of abortion, have no hesitation in treating botched abortions, either by medical treatment, or surgically. Said Ansari of Shirkat Gah, “They are open to treating post-abortion complications, including infections caused by mishandling or unskilled care.”
Abortion services are mostly offered by community midwives or at private clinics in a very clandestine setting. While Lady Health Workers (LHWs) are more open to referring those who wish to abort their foetuses, other service providers refuse to entertain any discussion on the issue, and even refuse to refer them. When asked whether she would offer abortion in a crisis situation a dai said, “Never, because even if I perform Hajj or Umrah, my sin will never be forgiven, for I would have killed an innocent child.”
Added Ansari, “Every year, 29 out of 1,000 women undergo unsafe induced abortions, and an equally large number of women seek medical care for complications resulting from unsafe abortions. So it’s critical to provide family planning counselling, address unsafe abortions and provide post-abortion care services at the local level.”
She continued, “Also essential are provincial level guidelines/policies for the provision of post-abortion care services. These need to be made available as a priority.
“We’re encouraged with the progress we’ve achieved,” she added, “but in a country with so much religious fundamentalism, one cannot explicitly address the issue of abortion due to fear of a backlash. As a result, we have to talk about abortion and post-op care indirectly.”
The abortion debate is not restricted to Pakistan. There are global ‘pro-choicers’ who believe that women should have the right to elective abortion; the right to terminate their pregnancies as a matter of personal choice, of bodily autonomy. And many also believe that the embryo is not an individual, therefore it has no rights of its own.
At the other end of the spectrum are the ‘pro-lifers,’ or those who oppose abortion on moral grounds. Worldwide, some countries ban abortion. Others, such as Britain, Canada and the US, permit it. Overall, abortion is permissible in 61 per cent of the world’s countries, and banned in the rest.
Many years ago, at the International Conference on Population & Development, 1994, Pakistan was a key player in facilitating recommendations for safe abortion. This was followed up within Pakistan in 1997, with a law permitting safe abortions within the first trimester. Besides being a medically correct stance, this was also in line with Islamic precepts, according to which ‘ensoulment’ of the foetus does not occur until the first 12 weeks of pregnancy are over. Unfortunately, this law was made unduly complicated with the introduction of strict Islamic punishments.
Now there is no relaxation of this law with all its additions, not even in cases of conception arising from incest, rape and gang rape, all of which are publicly known to occur in high numbers.
The majority of women, therefore, have little option but to seek hidden, back-street abortions by unqualified daisand others, invariably under unhygienic circumstances.
The results are near-inevitable – high incidence of septicaemia ( a critical illness when infection spreads throughout the body via the blood stream), severe bleeding, and several other life-threatening and debilitating complications, some of which may last a lifetime.
Against this backdrop, is a contraceptive prevalence rate that has stubbornly remained a low 30 per cent. And while the total fertility rate per woman has come down to 3.8 children, it still remains too high.
Sadly, support at the government level is still too little, too late. Easily accessible round-the-clock reproductive health and family planning services remain either inadequate or absent, as does the large-scale distribution of contraceptive facilities to all parts of the country, especially far-flung, hard-to-reach areas. Awareness-raising at the national level is particularly important, so as to highlight issues of women’s gender equality within the home and outside; the importance of their nutrition and health; and the need to reduce widespread son preference.
In these circumstances, improved facilities for safe abortion are an imperative, or will we always be caught on the wrong foot – forcing women to resort to having dangerous abortions and dealing with the consequences?
In the words of the world-renowned former Executive Director of UNFPA, Dr Nafis Sadik, “What culture worth the name would deny women the right to safe motherhood? What value system would send ignorant young people into the world, when a little knowledge might save their lives?”
Since 1998, abortions carried out, both before and after the unborn child’s organs have been formed, are prohibited in Pakistan, except when performed in good faith for the purpose of saving the life of the mother or providing ‘necessary treatment.’ Islamic law considers abortion feasible within the first trimester, or 12 weeks, when ensoulment of the embryo has not yet occurred.
The different stages of pregnancy are defined in terms of the formation of organs or limbs according to Islamic law principles. However, it is not clear what the definition of ‘necessary treatment’ is.
Though the Pakistan Penal Code makes provision for abortion if the life of the mother is endangered, the fact that no data is available concerning legally induced therapeutic abortion, indicates restrictive interpretation of the law by the medical profession.