KARACHI - For thousands of Pakistani women, the World Population Day message of 'Family planning is a right, let's make it real'' must sound hollow when they must resort to unsafe, illegal abortions while a debate on whether termination of pregnancy is Islamic or not rages on.
A 2004 study 'Unwanted pregnancy and post-abortion complications in Pakistan,' carried out over a two-year period by the Population Council of Pakistan, was an eye-opener. It said some 29 of every 1,000 Pakistani women of reproductive age seek to terminate their pregnancies and that an estimated 890,000 abortions were occurring in Pakistan annually.
But whenever activists and health practitioners, who regularly witness women dying from pregnancy-related complications, bring up the issue it only gets more entangled in an irrelevant debate over whether or not terminating a pregnancy (matured beyond 120 days) is un-Islamic and, therefore, illegal.
It does not help the pro-abortion or pro-choice advocates that even liberal Islamic scholars such as Khalid Zaheer reiterate that terminating a pregnancy after 120 days of conception is the "gravest of sins" committed unless the mother's life was in question.
Islamic scholars in Pakistan and in neighbouring India have interpreted the 'hadith' (sayings of the Prophet) to say that pregnancies that have not advanced beyond 120 days is permissible, indicating that the idea of abortions in not completely forbidden in the religion.
But Zaheer says that he does not have a "simple and straightforward" answer to abortion except that it "should not be for trivial or flimsy reasons'' such as limiting family size.
And so a dilemma that many women and their doctors face constantly remains unresolved. "What should we do when a woman comes to us requesting termination (of pregnancy) and we turn her away because it is illegal, knowing full well that she will go to some backstreet clinic and get an unsafe abortion?'' asks a young doctor at government-run hospital. ''The same woman then returns either half dead or with serious complications."
With a dismal maternal mortality ratio of 500 deaths per 100,000 live births and official acknowledgement that everyday 68 women die from pregnancy-related problems Pakistan must take quantum leaps just to meet the fifth Millennium Development Goal of reducing maternal mortality by three-quarters by 2015.
According to Dr Shahida Zaidi, vice-president of the International Federation of Gynecology and Obstetrics (FIGO), of the 46 million induced abortions each year globally, nearly 19 million are performed in unsafe conditions or by unskilled attendants resulting in an estimated 68,000 or a whopping 13 percent of preventable deaths. Of these 99 percent occur in developing countries.
FIGO is currently working in parts of the backward province of Sindh to reduce unintended pregnancies and induced abortions by improving access to safe abortion and post-abortion care in Pakistan.
A smaller scale study conducted by the National Commission for Maternal and Neonatal Health in collaboration with the Society of Obstetricians and Gynecologists of Pakistan, in 2007, found the situation no different from the 2004 Population Council report.
"Abortion in Pakistan is used primarily as a family planning method," says Dr Azra Ahsan, research leader. "Most women interviewed wanted to terminate because of birth spacing or because their family was complete."
"According to our research, 36.81 percent of abortions were conducted by unskilled traditional birth attendants (TBAs). The paradox here is that all the training is provided to doctors, nurses and lady health volunteers but never the TBAs," she said. Traditional methods used are either dilatation and curettage (DNC) or laminaria stents (sticks of seaweed which absorb fluid and swell), neither of which are recommended by the World Health Organisation. "It seemed relevant to start a debate after the Population Council came out with its study, to thrash out a consensus on the contentious issue of abortion," says Dr Yasmeen Sabeeh Qazi, senior country advisor with the David and Lucile Packard Foundation. "But it seems to have been dragged on for far too long," she told IPS.
Her foundation supports safe abortion practices, and, to give it a more digestible cover, uses the terminology 'post-abortion care,' often used by the government itself so as not to pique people unduly.
She feels that the biggest stumbling block towards making abortion legal in Pakistan is "doctors and healthcare providers who are convinced by outdated, conventional medical education that this is unethical and thus totally illegal".
She, however, is not in favour of initiating another round of debate on legalizing abortion. "I personally feel that we should let sleeping dogs lie. No one has ever been prosecuted in Pakistan for inducing an abortion but the moment we take the issue up for legislative changes, there is a risk of ruffling many feathers."
According to Qazi, existing law has ''sufficient room for manoeuvre by doctors and providers for practicing safe abortion''.
With abortion illegal, safe abortion services naturally remain elusive, forcing women to turn to backstreet clinics run by untrained TBAs, despite the risk of complications. According to Dr Shershah Syed, a practicing gynaecologist at the government-owned Qatar General Hospital, complications include "bleeding, infections, septic shock, perforated uterus, perforated bowels and, if they have survived these, infertility and chronic pain syndrome".
While legalising abortion may result in safer abortion practices, examples of other countries where laws are more liberal (like Nepal and India) have shown that clearly it will not stop women from terminating their pregnancy through unsafe means.
"It points towards a high level of unmet need for family planning (FP) services," explained Syed. "They want to either space or limit family size''. He put the blame squarely on the shoulders of the government for its failure in improving access to family planning services.
Most abortions are carried out as a means of preventing unwanted births, according to studies. Reasons cited for not using contraception include inaccessibility of FP services, financial constraints and in some cases differences between husband and wife over the size of the family.
"One major obstacle to the use of contraception is the fear of health side effects and misperceptions: it appears that many Pakistani women and men regard continuing contraceptive practices more threatening to their health than an occasional induced abortion," states the government's report.
© 2008 Inter Press Service