Whether they live in countries where abortion is legal or not, the reality is that women the world over have always found ways to terminate unwanted pregnancies. And where the law of a country makes it difficult and illegal to have an abortion, women have often resorted to dangerous methods that include undergoing the procedure at the hands of an unskilled ‘abortion’ specialist and even opting for self-induced terminations. An unsafe abortion is defined as “a procedure for terminating an unintended pregnancy carried out either by persons lacking the necessary skills or in an environment that does not conform to minimal medical standards, or both.”
Methods of unsafe abortion include drinking toxic, inflicting direct injury to the vagina or elsewhere, placing a foreign body into the uterus and placing inappropriate medication into the vagina or rectum. An unsafe abortion performed at the hands of an unqualified ‘abortion specialist’ who performs a D&C’s in unhygienic settings, can cause infections and uterine perforations.
Under Pakistani law, abortions are well encased within narrow confines that allow the procedure only under the most ‘necessary’ of circumstances, such as to save a woman’s life or to provide ‘necessary treatment’. The restrictive law, the high cost of getting an abortion and the stigma that surrounds the procedure is only partially successful in checking what is deemed as ‘unnecessary’ abortions. Ironically this has lead to the establishment of a market for back-alley abortion practices run by a host of under-skilled dais (traditional birth attendants) nurses and Lady Health Visitors (LHV) who will do the deed for a relatively small fee. Thus every year thousands of Pakistani women stuck with unintended (and not necessarily unnecessary) pregnancies, risk their health and lives by visiting traditional dais, nurses and Lady Health Workers, (LHW) who mete out a service for a very real demand.
The situation is exacerbated by the high number of unplanned pregnancies in Pakistan. It is estimated that 25pc of the births in Pakistan are not planned. General ignorance and misinformation about contraceptives have lead to the relatively low level of contraceptive use (about 30pc) amongst married women aged 15-49 years in Pakistan. A study conducted in 2002 found that the number of terminated pregnancies loomed close to 900,000 that year. That is, some 29 abortions for every 1,000 women of reproductive age.
Unfortunately because unsafe abortions are performed clandestinely by unskilled individuals or by pregnant women themselves the data on unsafe abortion is unreliable however the World Health Organisation estimates that in the Third World one woman dies every eight minutes due to complications arising from unsafe abortions. According to the Pakistan Demographic and Health Survey 2006-2007, about 6pc of maternal deaths are a result of complications caused by unsafe abortions. Worldwide this figure stands at 13pc, making it a leading cause of maternal mortality. The main causes of death from unsafe abortion are due to haemorrhage, infection, sepsis, genital trauma, and necrotic bowel.
Even though most women survive an unsafe abortion, many continue to suffer health complications such as poor wound healing, infertility, and the consequences of internal organ injury. In Pakistan the proportion of women thought to have developed complications from abortion procedures performed by traditional birth attendants ranges from 55pc to 68pc amongst rural women. When abortions are performed by LHV or nurses this figure falls to between 41 and 49pc, compared to a relatively lower 10pc when the abortions is performed by gynaecologists.
Perhaps the saddest and most frustrating aspect in all this is all this is that many of the deaths and medical complications caused by clandestine and unsafe abortions are completely preventable. Because of the stigma surrounding the topic, the number of unsafe abortions remains under-reported and so often the resulting medical complications are concealed.
Apart from the stigma, another major deterrent to seeking proper medical care is the high cost of getting a legal abortion. The cost of a first-trimester abortion can be forbidding for the average Pakistani as compared to the services provided by traditional birth attendants, midwives and nurses. In 2012, the cost of getting a first-trimester abortion by a traditional birth attendant or dai was Rs2,000-3000 whereas a LHW or nurse would charge about Rs3,000-5,500.
Even though restrictive abortion laws and low contraceptive use have contributed to the practice of unsafe abortions, it is clear that even if these issues are overcome women and health providers need to be educated about contraceptives, safe abortions and safe post abortion care. Otherwise, faced with the prospect of unintended pregnancies, the resulting stigma and financial burden, women will continue to risk their lives by undergoing unsafe procedures.
