June Issue 2019

19-year-old Alina* fidgets with her hands as she awaits her post-abortion check-up. A week since she first came to the clinic for the procedure, memories of the day she was compelled to abort her first child remain fresh in her mind: memories of feeling “completely numb” and “deeply saddened.”

Alina and her husband had not been using any contraceptive methods, so news of the pregnancy was no surprise. But only five months into the marriage and straitened financial circumstances, having a child was completely out of the question. “This was one of the most difficult decisions I have ever taken in my life,” says Alina, as her voice begins to break and tears threaten to fall.

According to a study conducted by the World Health Organisation and the Guttmacher institute in 2014, an estimated 25.1 million unsafe abortions are performed every year around the globe. Pakistan accounts for eight per cent of that staggeringly high number.

The Population Council estimates around nine million annual pregnancies in Pakistan, over half of which are unintended, with 2.25 million ending in abortion. The technique used by the Guttmacher Institute to estimate this number relies heavily on reported cases of women seeking post-abortion care in hospitals around the country. But with no possible way of knowing how many cases go unreported, the actual number of annual abortions in Pakistan could be significantly higher.

Although sexual and reproductive health rights are not explicitly mentioned in international covenants or the human rights charter, more specific conventions like CEDAW (Convention on the Elimination of all Forms of Discrimination Against Women) state, in great detail, the rights that should be extended to women around the globe. The United Nations sustainable development goals have also made both, gender equality, and good health and well-being, a consistent priority, but results vis-à-vis both remain unachieved in Pakistan.

Cases in Point…

A clinic manager in Karachi details the kind of patients she has dealt with in her year-long run at the facility that provides abortion services to women. “I once received a 16-year-old patient who was accompanied by her mother, both women clearly scared out of their wits and sobbing uncontrollably,” she says. The 16-year-old in question hailed from a conservative Pashtun family where she had been sexually violated and repeatedly raped by an elder cousin. “I can never forget how badly the women were shaking and begging for help,” she adds. The women were, however, completely averse to the idea of informing an elder male in the family, let alone reporting anything to the authorities. “All they wanted or cared about was getting rid of the pregnancy before anyone in the family found out. The shame was much greater than any trauma – physical and emotional – that had been caused to the girl for no fault of her own,” she says. 

Despite being one of the founding UN members and a signatory to CEDAW, policy level changes guaranteeing women the right to their own bodies have been limited in Pakistan. Socio-cultural norms, societal taboos, and lack of a clear distinction between religious jurisprudence and the law of the land, have collectively made it impossible for legislative changes to be implemented without raising any alarms.

But even as the legality of the issue is debated upon, large numbers of Pakistani women seek abortions every day, often by clandestine methods, in back alley clinics. Sadia, a 35-year-old mother of two, conceived her third child a few years ago. With her youngest only a few months old, she was determined to terminate the pregnancy. “Financial constraints aside, I was neither physically fit nor mentally prepared to have another child so soon,” she says. Sadia speaks of her abortions – in the years that followed she had two more unintended pregnancies that ended with abortions – with surprising nonchalance. But her experiences have been far from casual; she turned to the doctors at the Civil Hospital to help facilitate the termination, but was refused any help. “I had no other choice but to turn to the clinic in my locality,” she says. A resident of North Karachi, Sadia says her area of residence is home to multiple ‘clinics’ – a misnomer because they operate much like “butcher’s shops” entertaining all kinds of clients. “They did not conduct any tests before the procedure and the anesthesia I was given was completely ineffective,” she recollects. At the time of the surgery, Sadia remembers fearing for her life, praying she would come out of the place alive. But her husband’s refusal to use condoms and the lack of other available methods of contraception forced her to turn to the clinic twice after that, until last year when she finally got a tubal ligation – a surgery to tie a woman’s fallopian tubes, preventing any chances of pregnancy.

Photographs from the Museum of Contraception and Abortion, Vienna, Austria. The evolution of abortion instruments from the 1900s to 2004.

It is not only the less affluent who have to avail the services of back alley abortion clinics – often at the risk of their lives. In an increasingly global rampaging social and electronic media environment, where connectivity has led to a new-age of socio-cultural norms and the shedding of many traditional mores, including sexual conservatism, many young women, poor and rich alike, are sexually active today. Sometimes these sexual liaisons result in unwanted pregnancies. The liberalism of their generation X parents notwithstanding, these young women are still averse to sharing this information with them. Resultantly: a back alley abortion, sometimes taking more than just the fetus’ life.

While there are no official statistics identifying the number of rape victims or unmarried women who seek abortions, they reportedly constitute a sizeable portion of the 2.2 million women seeking this procedure in Pakistan annually. For example, while speaking at a panel at the Karachi Literature Festival in 2018, Dr Sher Shah Syed, former president of the Society of Obstetricians and Gynaecologists of Pakistan and founder of the Pakistan National Forum on Women’s Health, revealed that in all his years as a medical practitioner he has received many patients seeking abortions who had conceived after being raped – often by family members.

Until 1990, abortions were only allowed to save the life of expectant mothers, but a small change was made to the language of the law in 1997. Implemented the same year, Article 338 of the Pakistan Penal Code now permits abortions not only to save a woman’s life, but also to provide “necessary treatment.” Providers who choose to assist women seeking abortions often interpret the phrase to include the consideration of a woman’s mental and economic well-being. “When a law is this vague, it leaves much to personal interpretation, which in a country notorious for its inability to separate state and religion, does more harm than good,” says lawyer Sara Malkani, admitting that the lack of clarity may benefit an already privileged strata, but largely makes abortions inaccessible for more vulnerable women in Pakistan.

“Because the law now leaves enough room for interpretation, even if only a handful of people understand it, providing abortion access will become much easier,” says Dr Sarah Saleem, assistant professor at the Aga Khan University Hospital, adding however, that making a hue and cry about the issue may ruffle the wrong feathers and negatively impact the progress that has been made. However, Sara Malkani holds a different opinion. She believes that until the law is explicit in its definition of the term “necessary treatment,” women will be denied access to safe abortions in public hospitals, and consequently forced to turn to back-alley clinics – where they remain at the mercy of untrained personnel, and the risk of complications is much higher. Malkani further adds that any changes made to the law should move into giving women more rights and “Backsliding from what we have right now will be extremely detrimental to women’s health,” she contends.

While the legal community, women’s rights organisations, and social activists continually advocate against the lack of reproductive choices available to women in the country, religious factions remain firm in their anti-abortion stance. According to Islamic jurisprudence, abortion is considered haraam until performed to save an expectant mother’s life. Views on this subject do, however, differ on the basis of fiqh, whereby some Hanafis, Malikis, Shafi’is, and Hanbalis allow abortion up until the period of ‘ensoulment’ – generally agreed to be 120 days. Other jurists from the same fiqh, namely Lakhmi (Maliki) and Marwazi (Shafi’i) meanwhile, allow abortion up until 40 days after conception, prohibiting it thereafter. Given the multitude of sects within the larger umbrella of Islam, reaching a unanimous conclusion on the issue any time soon seems highly unlikely.

“This body is given to us by Allah, and He alone has every right over it,” maintains Mufti Imran, director of the Seerat Encyclopedia Project at the Dilshad Begum Foundation. He continues, drawing an analogy between abortions and organ donation, explicitly stating how neither is permissible according to Islamic law. “The Prophet (PBUH) took pride in the growth and multiplication of his ummah, so for mere humans to have the authority to stop that process is completely out of the question,” he adds matter-of-factly.

Both Mufti Imran and Pakistani law make no mention of abortion in cases of premarital sex, conception as the result of rape, or the course of action in case of fetal anomalies. The former two situations are usually regarded with great contempt in medical circles, but abortions due to fetal anomalies and the possibility of disabilities after birth are widely performed in both public and private healthcare facilities. Considering that the law makes no distinction with regard to any of the aforementioned situations, it is mainly the service providers’ prerogative to provide or deny access to abortions based on their respective personal views on the subject.

Although the law allows some room for interpretation, provider biases seem to be set in stone. When talking about the attitudes of local doctors, Bushra, field visitor for an international non-governmental organisation (NGO) that advocates for, and provides safe abortion services, calls the doctors “completely rigid” in their opinions on women who seek termination of their pregnancies. “Doctors even refuse to refer their patients to safe abortion facilities, let alone perform them themselves,” she adds, shaking her head disappointedly.

Denying women the right to make informed decisions about their own bodies is a legal, religious, moral and patriarchal problem in Pakistan, but unlike the West, this crucial issue hasn’t ever been able to occupy centre stage in the country’s political discourse. “We have to be able to keep the morality of it aside, and look at it for what it is – a human rights issue,” says Naureen Lalani, manager SRHR (Sexual and Reproductive Health Rights) at Aahung, an NGO that aims to improve sexual and reproductive health in the country.

Cases in Point …contd

A resident of Haripur, Rabia got pregnant seven times during her 13-year long marriage. She recounts the saga of her last and most painful pregnancy, and how it changed her life – in the worst ways imaginable. Unaware of her condition, she went to a privately run hospital near her village following weeks of nausea and lethargy, only to learn that she was three months pregnant. Still trying to digest that information, she was told her child had no heartbeat. And that left the 28-year-old with no option but to abort.

“The hospital asked for a Rs 8,500 fee to do the needful, which my husband refused to pay. Left with no other recourse, I turned to the local dai for help,” she says. Rabia describes the midwife’s operation theatre as a “small dark room,” where she kept a few surgical instruments and helped the village women deliver and abort babies. “Relatively painless to begin with, the procedure turned into a nightmare in just a few a minutes: I felt the dai was actually pulling out pieces of my uterus. I had had other abortions before, but none this painful,” says Rabia, adding that after a while she could feel assorted instruments being inserted all the way up her uterus, and in the process, the dai damaged a vein that caused her to black out. Now concerned, the dai asked the neighbours to help. They rushed Rabia to a hospital in the city. “I was told that the dai had completely removed my large intestine during the procedure,” says Rabia. Meanwhile, her husband refused to pay for her procedure, and following the ordeal, abandoned Rabia and her children, sending them to her parents’ house in Karachi. Thereafter, still ailing, Rabia underwent several surgeries at the Indus Hospital in Karachi where she was given an external stomach bag for four months before her intestine was reconstructed. The damage done to Rabia’s uterus however, is irreparable.

Despite the silence on the subject and the regressive stand taken on it by the conservative segment of Pakistani society, there has been no known persecution of medical personnel for providing abortions to date. Ironically, in most cases, it is the healthcare professionals themselves who choose to restrict women’s access to safe abortions due to their personal moral reservations. When speaking about the legality of abortions, Farhana Naz, a community midwife trained by the Greenstar initiative, categorised all abortions provided to unmarried women, sex workers, and victims of abuse, as “illegal,” while deeming the instance of a married woman being forced to abort due to societal pressure entirely valid. Interestingly, the law makes no such distinctions. Naz’s misplaced understanding of the law hints at a much larger problem: there is a complete vacuum with regard to rights-based conversation in the prevailing medical discourse in Pakistan.

According to Dr Qudsiah Hassan, head of forensic sciences at the Ziauddin University Hospital, medical academia in Pakistan is not conducive to interactive learning, and professors are likely to push their personal agendas forward instead of teaching objectively. Provider biases stem from the first step of the medical education system when topics like abortion are taught in very little detail, and under the forensic sciences umbrella, going further by indicating a criminal association with this already controversial subject.

Dr Habibah Sharaf Ali, Obstetrics and Gynaecology professor at a private teaching hospital, sees around 15 to 20 patients every day at its Keamari branch. A significant number among them come in seeking abortions, but hospital policy does not allow her to serve them in any way. “I often receive clients from the poorest households, with absolutely no means to allow them to continue their pregnancies, but irrespective of my personal views, I have to turn them away because of workplace policies,” she says. She goes on to recount a case from a few years ago when an unmarried girl came in asking for an abortion. Instead of providing her safe healthcare, however, the administration decided to inform her brother, who took her away immediately. “The very next day we received news of the girl’s death,” she adds, her eyes involuntarily tearing up.

“Regardless of how strict a law might be, abortion remains an undeniable reality in Pakistan and the world over,” says Dr Ali. She contends that the medical community will always remain divided on the issue, and even those who claim to be on the women’s side, have failed to make any fundamental changes within the system.

After shuffling through her drawers for a minute, Ali pulls out a hospital consent form for medical procedures, pointing to a distressing detail: there is no space for the signature of the patient in the case of abortions. All gynaecological procedures require the signature of only a consenting male – the husband in case of a married woman, and any male guardian if the patient is unmarried.

“That is the extent of control hospitals allow a man over a woman’s body, and no one even bats an eyelid,” she says, her voice laced with disgust.

Religious restrictions and provider biases notwithstanding, the lack of contraceptive awareness in Pakistan has been constantly highlighted in independent studies conducted by organisations like the Population Council and Shirkat Gah. Afshan Khan, senior manager of the SRHR (Sexual and Reproductive Health Rights) unit at Shirkat Gah talks about the lack of reproductive options available to women. Talking specifically about the women residing in rural areas, she says they are “the most vulnerable of the lot, with even fewer options of safe reproductive and abortion healthcare than women in cities, who are themselves so deprived.”

In 2013, the results of the national demographic and health survey concluded that only 26 per cent of Pakistani women actively use a family planning method, and shockingly, 37 per cent of those women discontinue using any form of contraception within the first year of use. “Misplaced beliefs such as that contraceptive use leads to infertility, make it impossible to educate people about its health benefits,” says Dr Habibah Sharaf Ali. The lack of contraceptive prevalence is also a problem rooted in patriarchy; men are often averse to the idea of contraception. A lady health visitor sheds light on reasons other than misplaced religious beliefs for the lack of contraceptive prevalence in Pakistan. “My clients often tell me that their husbands refuse to use condoms because it makes sex less enjoyable for them,” she says, leaving the responsibility of birth spacing entirely on the woman. “It is equally alarming that STDs are not a consideration for them either,” she adds.

On March 18, 2018, the Ministry of National Health Services, Regulations and Coordination, released a set of guidelines for ‘safe uterine evacuation and post-abortion care.’ The guidelines necessitate the ease in availability of misoprostol, a WHO-recommended abortion pill, which until recently remained largely unavailable over the counter. However, since healthcare decisions are not legally binding and policies in Pakistan are largely in the control of provincial governments, each with their own view on the issue, while the guidelines released are fairly progressive, they do not do not make safe abortion care widely available to women in Pakistan. It also does not help that the local media has contributed to this dismal situation. It has played a largely negative role, feeding into stereotypes and adding to the stigma attached to abortions in this part of the world. A little over a year ago, a local news channel raided a non-governmental family planning centre under the pretext that an unmarried woman seeking termination of her pregnancy was being provided the service at this centre. A year later, most of the people who then worked at the clinic have left, but the new staff is more resilient. “The need for abortions isn’t going anywhere in this country, so neither are we,” says a paramedic at the facility located in the heart of Mehmoodabad, Karachi.

Demanding Agency: A woman holds up a sign during the Aurat March, 2018.

Sara Zaman, former director of the Bodily Rights Programme at Shirkat Gah, draws a connection between patriarchal conditioning and the lack of choice provided to a woman. “Limiting women’s ability to make informed choices about their bodies deprives them of a fundamental right that should ideally be guaranteed by the law,” she says, further adding how the pro-choice movement is the need of the hour in Pakistan, where women are constantly being pushed to the margins and backed against a wall.

Pro-choice does not, of course, necessarily mean pro-abortion. Zaman sheds light on the other side of the coin, where in a male-dominated society like Pakistan there is no way of knowing how many of the 2.25 million annual abortions are performed under coercion.  Irrespective of whose decision it might have been, “even though it most certainly should be the woman’s alone, society always finds a way to further disempower the already weak and vulnerable,” she says.

The legality and morality of abortion aside, there are real and oftentimes harrowing personal stories of poverty, psychological duress, the unimaginable guilt, and emotional loss and trauma of the women seeking abortions. And these crucially important factors surrounding abortion often get ignored. Women are forced to stay silent about their experience due to the fear of stigma and moral judgement and in the worst case scenario – of legal persecution.

A resident of DHA, Karachi, recounts her story from 12 years ago, when she unexpectedly conceived at the age of 40. On being informed of the possibility of her children – she found out she was carrying twins – being born with special needs, she decided to abort. But the decision was far from easy. “What people don’t understand is that irrespective of her circumstances, irrespective of her reasons, a woman goes through hell and back when taking such a decision,” she says. Despite the numbers, abortion does not make for dinner table conversation, and women continue to suffer in silence. “What I would have given at the time to speak to someone who had the same experience as me,” adds the now 52-year-old.

A political issue that continues to polarise people around the world, in Pakistan, despite the glaring need to address the issue, abortion is anything but a national priority. As a consequence, women are often subjected to torture having to terminate unintended pregnancies, after being left at the mercy of untrained personnel. Farhana Naz recalls the case of one of her clients, Faiza, a young mother of one who repeatedly carried buckets of water up the stairs of her house and asked her daughter to jump on her back, trying any and every method to end her pregnancy. She did not succeed. Faiza is not alone. Women have been known to use harmful methods to end unwanted and unintended pregnancies. A report published by Shirkat Gah details the various unsafe methods women use in attempts to terminate unplanned pregnancies.

From drinking boiled herbal concoctions, to the insertion of sharp objects in their uterus, women resort to a range of often life-threatening methods which sometimes result in serious medical complications. In fact, an article published in JPMA (Journal of the Pakistan Medical Association) indicates that unsafe abortions are a major cause of growing maternal mortality and morbidity in Pakistan.

The bottom line – pressure from NGOs and independent activists is not enough to result in a cultural shift. Despite restrictive laws and provider biases, the number of annual abortions in Pakistan continues to rise – clearly indicating that sweeping it under the rug will not help solve the growing issue. Legislative change, the separation of state and religion, along with a more well-rounded medical curriculum that looks at abortions outside of the forensic science lens could be a first step in the long journey towards providing women the right to determine their own reproductive situation. So far, however, nothing coming close to any of these seems to be on the anvil. 

Behind Closed Doors

Large trees line the corner of the street. The building on the far edge remains unpainted from the outside, making it disappear even as it stands otherwise tall in the busy neighbourhood of Mehmoodabad, Karachi. A lone man in uniform guards the entrance, taking cover from the scorching Karachi sun under the shadow his workplace casts on the ground.

The clock is yet to strike nine but two women are already standing outside the clinic, anxiously waiting for the doors to open. “How much longer until the staff arrives?” asks the older one of the two. Located in the heart of Karachi, the clinic receives around 20 patients daily, at least half of whom are there seeking abortions.

For a small private clinic in Karachi, abortion is just business as usual.

While there is no dearth of OB/GYNs in the city, walking into a doctor’s office and asking for an abortion is an entirely different story. But despite the questionable legality of their job and the risks it entails, the clinic staff is here every morning, ready to take on the day’s challenges.

The women waiting at the doors breathe a sigh of relief as one of the staff members shows up right on time, and ushers them inside. “I’ve had people, even friends and family, shame me about my job. They go so far as to label me a murderer,” says the manager at the clinic, as she schedules meetings for the day. An employee at the clinic for little over a year, she speaks of her experience thus far. “In just one year I’ve seen the kind of realities of this country that most people don’t in an entire lifetime.”

The clinic is modest, few chairs lined against the wall form the small waiting room, and a male receptionist sits behind a desk against the opposite wall. A well-equipped clinic, where women are facilitated if they opt to terminate a pregnancy, is a rarity in Karachi, and so, it receives women from all over the city. “From the poorest of the poor, to the wealthy and privileged, almost every day we get a full spectrum of clients here,” says Narmeen*, the in-house paramedic.

Meanwhile, as other staff members  keep coming in, it will still be another 30 minutes before the clients can be entertained. The all-female staff, with the exception of the male office receptionist, goes up to the first floor to change into their bright blue uniforms. Work finally begins at 9:40. Thirty-year-old Fatima*, accompanied by her elder sister, walks up to the receptionist who directs her to the in-house counsellor upstairs. Rabail* welcomes Fatima into her office with a warm smile. Looking through the client’s ultrasound report, she begins the conversation. “My job entails informing the client of all possible options, keeping medical limitations in mind, but the final call is always theirs,” she says, just as Naveen, another member of the staff, comes in to hand her a cup of tea. Rabia spends the entire day catering to one client after the other. “I will admit, it’s not the best of places to work in,” says the 23-year-old, “however it’s not half as bad as people might believe it to be,” she adds.

All possibilities in mind, Fatima decides to take the counsellor’s advice and opts for a medicinal abortion, followed by a D&C – a surgical method used to remove remaining tissues from the uterus to avoid any infections.

At the clinic, the law is not much of a consideration. “Abortions aren’t going anywhere in this country, so neither are we,” says Narmeen. She is one of the few staff members who clearly remain free of guilt, and are unaffected by the stigma. “Some colleagues of mine feel embarrassed in telling people about their workplace, but I’m proud of the work we do here,” she adds in her naturally confident tone of voice. The head paramedic firmly believes that she wouldn’t have found her way there if God didn’t want her to.

However, Narmeen’s views do not represent the bigger picture. Abortions in Pakistan are stigmatised on the basis of both, religion and socio cultural norms, by a large section of society. “I keep telling clients that they chose to come to us, nobody dragged them to the clinic,” she says while recalling an incident when a patient’s attendant confronted her about the morality of her line of work. The hypocrisy extends to people’s conflicting views about abortion and contraception. “I have had men bring their wives to me for multiple abortions, but when I advise them to use contraception the discussion suddenly boils down to religious views,” she adds, hinting at the larger issue at hand: how religion in Pakistan is used selectively, sometimes only to facilitate men to keep their societal dominance intact.

In the clinic, Fatima’s decision to abort challenges this very notion; not only has she decided to keep the news of her pregnancy from her abusive husband, she also plans on filing for khula soon after the abortion. Five years ago, Fatima went against her family’s wishes to marry a man of her choice. Today, there’s nothing she regrets more. Extremely impoverished, living a miserable life with a drug-addict husband and two young children, Fatima lacks the financial means to raise another child. She also does not want bring another child into the abusive environment of her home. Just as she changes into a dressing gown to prepare for the procedure, the sound of the azaan from the nearby masjid echoes in the room. “I’m not entirely sure what to make of this; is God giving me the green signal or is this His way of telling me to stop,” she says rhetorically with a throaty laugh that doesn’t quite reach her eyes.

On the flip side, the clinic staff is a little worried about what this might mean for them. About a year ago, they were subjected to abuse at the hands of a scorned husband whose wife made the same choice as Fatima’s. “The danger of this job never really goes away,” says the clinic manager.

Fatima’s procedure has ended and she’s ready to leave. Physically, she says she feels fine, but is now beset by conflicting emotions. “The worst part is that I cannot even think of talking about my feelings with anyone, not even my family,” she says, adding how they would embrace the chance to make her feel terrible about the decision, instead of offering support. Asking her sister to wait downstairs, Fatima goes back to the counsellor’s room, hoping she can have a word before leaving, but clients are lining up in the waiting room and Rabail has to move quickly. There is no time for an emotional meltdown. 

 

*Names have been changed to protect identities.