June Issue 2010

Marium Masih is a well-respected dai who lives in the French Colony, a katchi abadi in the heart of Islamabad’s F-7 sector, behind the popular Jinnah Super Market. While deliveries are done at the client’s house, abortions on women more than three months pregnant are conducted in a small one-bedroom space she has rented in this predominantly Christian slum. In most of the cases, in what is a short procedure, Masih inserts a hook-like stick into the woman’s womb along with a homemade herbal tablet and asks her to return home and continue with her daily chores. Within 24 hours, the woman ‘expels’ what is actually a fetus, terminating an unwanted pregnancy.

A single parent with five kids to support, Masih conducts five to six deliveries a month, making Rs 4,000-5,000 per delivery. As for an abortion, “it depends on the stage of pregnancy. It’s 1,000 for each month plus what they want to give apni khushi sey,” she says candidly.

The rates for terminating an unwanted pregnancy for Shahnaz Bibi are much higher. Known as Sister Shahnaz in the Satellite Town neighbourhood, she charges Rs 5,000 for a normal delivery, but the charges for terminating a pregnancy depends on the number of weeks. “She is not a nurse. Never was,” discloses Dr Ayesha Irfan, a resident of the area. “She was a maasi (cleaner woman) in a government hospital in Rawalpindi but due to her expertise in delivery, everyone calls her Sister.” Most women who come to her seeking induced abortions are married with three or more children.

The World Health Organisation terms unsafe abortion as “a procedure for terminating an unwanted pregnancy done by persons who may lack the necessary skills or is conducted in an environment that lacks the minimal medical standards, or both.”

Although a widespread phenomenon, (induced) abortion is a highly stigmatised issue in Pakistan, pushed under the carpet every time any one stands up to raise it. The figures from a 2004 Population Council study, “Unwanted pregnancy and post-abortion complications in Pakistan,” reveal that some 29 of every 1,000 Pakistani women of reproductive age seek to terminate their pregnancies and that an estimated 890,000 unsafe abortions are carried out in Pakistan annually. Almost 90% of these occur among married women between the ages of 15 and 49.

The Population Council study is very informative and probably the only one that is referred to again and again in Pakistan. Experts believe the numbers have only increased in the past six years. “We do need to revisit this situation as a whole. Whether this will take the form of another study is still undecided at this time,” says Dr Zeba Sathar, Pakistan country director for Population Council. Revisiting the situation is critical because most women seeking private abortions are oblivious to the risks to their own lives.

According to Dr Shazra Abbas, a gynaecologist formally working at the Pakistan Institute of Medical Sciences (PIMS), Islamabad, when a woman does not want another child yet becomes pregnant, she may seek an induced abortion. Those who are unable to afford or access these services or are turned away by a qualified medical practioner due to the legality of the issue try to abort the pregnancy themselves, opt for dais or turn to back-street clinics run by unskilled people in unsterile environments.

Termination of pregnancy by untrained providers, says Dr Abbas, “results in complications such as haemorrhage, sepsis, infection or perforated uterus.” Patients coming to her with post-abortion complications are “either very young or at the last stage of their reproductive cycle.”

“We [in the public sector] only entertain those who seek abortion on medical grounds, that is, if the baby is abnormal or the mother’s life is at risk of for any reason.”

The private sector makes its own choices, says Dr Riffat Shaheen, head of the department of gynae and obstetrics, at the federal government’s Polyclinic in Islamabad. Her department has 160 beds and has an annual delivery rate of 7,000-8,000. “About 20-25 deliveries take place per day,” says Shaheen. “Women who come to us for termination of pregnancy are mostly married and the ones not practicing family planning. The reason they give for seeking abortion is to limit their family size, or to space out the births, which they have failed to do through the use of contraceptives.” During her OPD days, Dr Shaheen had come across many women with ruptured uteruses and other post-abortion complications. “All of them come from these back-street clinics run by dais but never disclose the names or whereabouts of these clinics,” she reveals.

“Most couples still feel inhibited by cultural/religious taboos to discuss abortion openly. Additionally, a lack of access to effective contraceptive services causes couples to seek such solutions. We are short of contraceptive commodity support. It’s too late in the day. We need to place it at the top of our priority list,” adds Dr Sathar.

Although Pakistani society is conservative, the law, according to the Society of Obstetricians & Gynaecologists of Pakistan, gives healthcare providers a lot of space. Till 1997, abortion was permitted only to save the life of a woman. But this was amended in 1997, and as a result of the amendment to the Penal Code, abortion is allowed in the early stages of pregnancy not only to save the life of the woman but also for providing “necessary treatment.” But very few are aware of this change. In 1997, the Commission of Inquiry on the Status of Women, headed by Justice (retd.) Nasir Aslam Zahid of the Supreme Court, which was set up to look into the laws to end the inequalities towards women, recommended, “A woman’s right to obtain an abortion by her own choice within the first 120 days of pregnancy should be unambiguously declared an absolute legal right.” But this still remains a recommendation.

According to global figures, nearly one in 10 pregnancies ends with an unsafe abortion. But this is a global estimate, combining countries where abortion is safe and legal with those where the procedure is prohibited or performed by an unskilled practitioner in less than sanitary conditions, or both. In low-income countries, women have an average of one unsafe abortion during their reproductive lives.

As of 2007, Pakistan’s maternal mortality rate stands at 276 per 100,000 live births. Every 30-40 minutes, a Pakistani woman dies of complications arising from pregnancy and child birth. The average number of births per woman in Pakistan currently stands at 4.1.

“The ‘A’ word, abortion, should be done away with and replaced by miscarriage,” stated Dr Nighat Shah, Obstetrician and Gynaecologist at the Aga Khan University Hospital, at a workshop on family planning held recently in Karachi. Dr Shah believes the word abortion is considered to be ‘synonymous with sin’ and associated with condemnation or discrimination against women who are in need of help. “At the end of the day, it’s her body, her right. A mother’s right should not be taken from her unjustifiably,” she says.

Society considers it a taboo and there is complete silence on the subject. People who are unaware usually avoid getting into the debate. But how long will we remain silent? It’s time to talk and bring abortion in discussions on various forums. It’s time to discuss the consequences arising from it and the suffering of the women who go through it — those who die and those who, according to Shah, “survive but are worse than dead.” The problem is that there is a dearth of information even among health professionals in Pakistan and the general perception is that abortion is illegal. “It’s time to announce that abortion is NOT illegal in Pakistan,” says Dr Shah.

This article originally appeared in the June 2010 print version of Newsline under the headline “A Fatal Choice.”