A woman’s health attains crucial importance in the establishment of a healthy society. The good health of a woman not only affects the individual but also impacts on society as a whole. As a matter of fact, a woman’s health is the wellbeing of a society and guarding this attribute is the responsibility of the entire social system. Amongst the many dangers to a woman’s health, unsafe abortion poses the largest dilemma and challenge. Presently, more than 200,000 women die annually due to unsafe abortions in the developing countries. It is estimated that approximately 46 million women undergo abortion throughout the world in a year. According to World Health Organization (WHO), as many as 670,000 women die annually as a result of unsafe abortion throughout the world. The irony is that the lives of many of these women can be saved through safe abortion methods and techniques.’ Unsafe abortion not only results in death but also causes internal complications, severe pain, and sterility. In addition to these, psychological problems can also arise.
Like many other countries, Pakistan does not allow legal abortions. Permission to conduct abortion is only provided in special circumstances where the life of the pregnant woman is at risk.
Clinics that provide abortion services are available in large cities although a large number of unskilled medical clinics are also abundant in some areas. A woman’s life is at grave risk in these unskilled medical clinics due to inadequate facilities and untrained staf£ According to a report by FPAP, only 22% of clinics in Lahore meet the minimum standard of medical facilities providing such services. Considered an illegal issue, the government, women organizations, lawyers working for women’s rights, and women parliamentarians all have adopted a passive stance regarding the risks posed to a Pakistani woman’s health and life. The importance of this issue has been overlooked in the past.
This booklet ”Woman’s Health – Road to Safety” elaborates this basic issue pertaining to woman’s health. It is hoped that this booklet will benefit those working on woman health issues and will inculcate the need to change legislature in this context.
What are the hard facts
Shirkat Gab, Women’s Resource Center, released a special bulletin in December 1996 entitled “Time to Speak Out” in which the research report findings of renowned gynecologist Prof. Dr. Mrs. Asghari Awan were highlighted. According to this report, in 1971 and 1972 out of 3,772 women admitted in the female ward of a Lahore-based hospital, 1,208 suffered from abortion- related complications. This meant that amongst all women who contacted • the hospital, approximately 32% were admitted for abortion services. Of these, 16% developed sepsis; 33.4% reported incomplete abortions and were forced to endure the agony once again. Amongst the women admitted for abortion or abortion-related complications, 72% of them were in the age bracket of 20-34 years.
According to an estimate, 54 out of 1,000 pregnant women undergo abortion in Pakistan but this statistic is 30 years old which surely must have increased, in the present scenario. A recent report by Aga Khan University on “Gender Perspective on Induced Abortion:
Knowledge and Attitude”4 has prepared new statistics on safe and unsafe abortions in Karachi hospitals. In Pakistan, the statistics and details on unsafe abortion are inadequate. Some statistics can be derived from maternal deaths during childbirth or soon after birth. Between January 1992 & December 1994, approximately 1,201 women with abortion-related complications were reported at the Civil Hospital, Karachi. Of these, 37% of them had abortions performed illegally. Of those who died from abortion-related complications, 15% of them had illegal abortions.
An extensive survey was conducted by the Department of Community Health Sciences of Aga Khan University on the issue of abortion, which revealed the following facts. According to the findings, many women had abortions performed due to their poverty-stricken conditions or out of compulsion. With limited income. and many children, they felt that another child would add to their problems. Some women even had abortions performed due to displeasure with their husbands and in-laws. The survey conducted by Aga Khan University revealed that women living in the Karachi katchi abadies and poor localities had abortion done due to poverty
and family conflicts despite knowing the outcomes and complications associated with the procedure. Above all they are even aware of the risk of death associated with abortion and most of these women have abortions with the consent of their spouse.
Abortion is a matter of life and death. In certain circumstances, it becomes compulsory. Hence it is the duty of women members of National and Provincial Assemblies, Organizations of Human Rights and Women and Legal •bodies to adopt a humane and sympathetic attitude with reference to the issue. It is mandatory to implement new legislation to curb thousands of lives at stake due to unsafe abortion.
Abortion Laws in the World
In most countries, abortion is allowed under certain circumstances. However, aspects such as the presence of equipped medical facilities, presence of trained doctors and staff, availability of funds by the government, and the general public beliefs and attitudes outweigh the legality surrounding abortion.
There are 38 countries that strictly forbid abortion. There are also many countries where abortion is legal but due to either scarcity of expert doctors or due to resistance on religious grounds, the provision of abortion services are hindered or difficult to acquire.
In more than 35 countries, including Pakistan, abortion is legal only when the continuation of pregnancy places the mother’s life at grave risk. However, in 54 countries abortion is legal without any conditions. These include United States of America, Canada, China, Turkey, France, Norway, and South Africa amongst many others.
Legal and Illegal Abortion
In countries where abortion is legal, a woman can have a safe abortion performed for a fee at any Health Center or hospital. In such countries, no woman falls ill or dies due to abortion-related complications.
In some countries, abortion is legal under the following circumstances:
• If a woman gets pregnant due to rape or due to incest (adultery by a
close family member);
• If a doctor feels that the woman’s life is at risk due to pregnancy;
• If the child has congenital disorders
Even in these countries, within the given circumstances, there are great obstacles involved in getting abortion services. In reality, whatever the legal status may be, doctors and health workers often disregard this. It may be possible that they don’t want to perform abortions openly or want to charge a substantial amount of money in exchange. It may also be the fact that women do not have the knowledge of whether abortion is legal or not and if such facilities are available in their country.
Safe abortion in accordance with the law may be difficult because it is too expensive and secondly women have to travel far distances for the service. The regulations are often complicated and women who seek abortions lose hope or find difficulties in the documentation procedures.
Because of these reasons, abortions can be extremely difficult for women who are poor, live in far flung areas, immigrants, and unmarried young girls who don’t have much knowledge regarding the medical system or safe abortions. Unfortunately, only those women who can bear the cost of a private doctor have the luxury of a safe abortion.
If the abortion is not in accordance to the laws then legal action can be taken against both the woman opting for an abortion and the person performing the procedure. Normally it does not lead to this because in those countries where performing or getting an abortion is illegal, most women who seek unsafe abortion and pregnancy often die. The amount of money that could have been spent on women health facilities is spent on unsafe abortion related complications. It is imperative that where abortion is legal complete knowledge should be available to women so that they can seek safe abortion. In such countries, even if abortion is the last resort, it should not pose a threat to the woman’s life.
Safe and Unsafe Abortion
If an abortion is performed using safe methods, it is no more dangerous than childbirth itself.
An abortion is safe when:
• It is performed by a properly trained and experience health personnel;
• Proper equipments are used;
• It is conducted in a clean, hygienic environment. All items inserted into the vagina or uterus are aseptic;
• It is performed within 3 months (12 weeks) of last menstrual cycle.
An abortion is unsafe when:
• It is performed by an untrained person;
Wrong equipments and improper medicines are used;
• It is performed after 3 months (12 weeks) of last menstrual cycle or unless it is performed at a health centre or hospital where adequate equipment are available.
Modern & Safe Methods of Abortion
A trained health worker, or a doctor can abort a pregnancy by using the following methods:
• Abortion through Vacuum Aspiration (MVA)
• In this method a special tube is passed into the uterus and abortion is conducted by numbing the uterine wall. This method can be performed without giving any anesthetic or sedatives to the woman. In order to avoid pain, certain medicine may be passed through the cervix. When MV A procedure is completed manually, the product of conception is removed by a special syringe or a small electric machine.
• Vacuum Aspiration (MVA) is simple, safe, and takes only 5-10 minutes to perform. It can be performed at a doctor’s clinic, health centre, or hospital. This procedure is best performed in the second month of pregnancy, butsome times it can also be performed at a later stage. Compared to Dilatation and Curettage, MVA causes fewer complications. At times the woman may not know she is pregnant and her only complaint is lack of regular menstruation. The procedure is known as Regularization of Menstrual Cycle.
• Dilatation & Curettage (D&C)
• In this method, the product of conception is scraped from the uterine lining using a curette. A curette is a small spoon-shaped instrument. It is especially made so that it can easily be passed into uterine cavity. Curette is larger than a canula, and since it is sharp¬edged, it is recommended to stretch and widely open the cervix prior to passing the curette into cavity. Stretching can be painful.
• D&C procedure takes relatively longer duration to perform approximately 15-20 minutes. In comparison to Vacuum Aspiration (MVA), D&C is relatively more painful and expensive. Normally this procedure is performed in the operation theatre and often requires anesthetic medication and sedatives.
Through Medicines (Medical Abortion)
Doctors and health workers use some medicines to cause abortion. As a result of these medicines, the uterus shrinks/ contracts and expels the fetus. Medicines are either administered intravaginally, orally, or parenterally by injections. If the appropriate medicines are administered for this purpose, it is comparatively better and safer than inserting anything in the uterus.
Situation in Pakistan
In Pakistan the ratio of illegal and unsafe abortions is very high. Numerous complications are encountered in a pregnancy. In addition to this, many women do not want to increase their family size. Some fall victim to spousal violence. Some unmarried women become pregnant due to extramarital. relations, rape, or incest, and because abortions are illegal in Pakistan, these women are forced to approach indigenous doctors, nurses, midwives, and birth attendants. These providers use extremely unsafe methods for abortion. As a result, many of these women have complications, which often lead to death.
On this note, even government officials accept that Pakistan’s high maternal mortality rate is due to the illegal status of abortion ~ permitted only when a mother’s life is at risk. Under such circumstances, no trained doctor will take the risk of conducting abortions. It is for this reason that many women are compelled to contact these unskilled doctors, midwives, and nurses who by using nonprofessional techniques place lives at risk for extraordinary fees.
It is essential to inform women the circumstances in which abortion is permitted and the dangers associated with unsafe abortion. Moreover, they should be informed that:
“They should use medicines for abortion on prescription of a doctor. A clinic or a hospital should be situated nearby so that in event of bleeding, she can be shifted there. Trained health staff should be available at the clinic or hospital so that the woman does not encounter complications.
Other women should be persuaded to refrain from the following practices:
• Do not allow the insertion of any pointed object e.g. wood, wire, or plastic tube. This could pierce the uterus and cause severe bleeding and infection;
• Insertion of herbs can cause severe infection or burning;
• Do not insert concentrated soap solution, bleach powder, etc.
Nor attempt to drink such solutions;
• Any effort to abort a fetus by taking overdoses of medicines can be fatal ( e.g. excessive use of quinine for malaria or oxytocin after the bleeding starts);
• Kicking the abdomen or jumping from height can result in internal wounds and severe injuries.
The Story of Lubna’s Disability
The story of Lubna is not an unusual one. Such stories are often repeated in poor and less educated families. Lubna gave birth to a child after one year of her marriage and due to ill health and weakness she nearly died. Doctors informed her and the husband that if she gets pregnant again before three years then it would pose a threat to her life. Despite knowing this, her husband Yunus did not take any precautions and within a year she became pregnant yet again. When Yunus came to know about this he gave her some medicines but nothing happened and four months went by.
The lady at whose place Lubna’s mother-in-law used to work gave her some money to bear Lubna’s abortion expenses. So Yunus took her to a clinic. The doctor informed Lubna that an abortion performed at this point of time would put Lubna’s life in danger. According to the doctor, abortion is illegal in Pakistan and if Lubna loses her life during the process then a legal suit could be filed against her. Having said this she asked Lubna to go back.
However, due to poor health and as a result of using medicines in the early stage of pregnancy Lubna had a miscarriage in the 7th month. She lost so much blood that her life was threatened. Five years have elapsed since this incidence and still Lubna has not recuperated and lies handicapped in bed.
Ten Basic points about Abortion:
1. Make sure that the woman who has decided to have an abortion is aware of the existing laws and is taking this decision without any pressure. She should be well aware of the procedure adopted, outcomes and related side effects.
2. Prior to abortion, assess the general health of the woman so that if she is suffering from any infection it should be treated before performing abortion. Assessment of gestation age of pregnancy
is very important.
3. Decision should be made regarding the method for abortion to be employed based on the gestational age of pregnancy.
4. The abortion should be performed only by a trained doctor, para-medic, nurse or midwife. Only such staff should be deployed who can conduct an abortion at any stage, and who also
respect the decision of the woman.
5. Strictly follow medical instructions and methodology, which include sterilization of equipment to be used so that the woman can be safeguarded from contracting any type of infection.
6. During the process the woman should be given moral support. If needed, anesthetics (methods for sedating and making a person unconscious) and other pain relieving medicines should be administered, but as little as possible. General anesthesia should not be given. However, if it is necessary, the procedure should be performed under the supervision of a trained doctor.
7. While performing abortion, converse with the concerned woman and counsel her on the available family planning methods. Ensure that the family planning products are readily accessible to her; never link abortion with adopting family planning practices.
8. Before sending the woman home, she should be briefed on all the signs and symptoms indicative of complications, the vital actions required and where to contact appropriate in case of emergency.
9. • Internal sepsis and incomplete abortion should be treated on an emergency basis. For this purpose the expertise of a specialist doctor should be sought. If blood transfusion is required then it should be done immediately. Necessary medicines should be given intravenously (injections administered through veins) and the required dose of antibiotics should also be given.
10. Assistance should be given to the women seeking abortion facility at the health centre. It should be ascertained that the health centre is equipped with trained staff, appropriate equipment, medicines and other necessary items required for abortion.