Pakistan International Peace & Human Rights Organization
Nindo Shaher District Badin Sindh Pakistan

WHO has estimated that out of the 500,000 maternal deaths worldwide each year, 115,000-204,000 result from complications of illegal abortions performed by unqualified practitioners. WHO also estimates that more than half of the deaths caused by induced abortion take place in South and Southeast Asia. (Henshaw and Morrow 1990: 81)

Policymakers in Pakistan are slowly recognizing that women practice induced abortion in this country, often in unsafe environments, and that this poses a public health problem. In the Pakistan Country Paper submitted to the 1995 Fourth World Conference on Women, the government estimated that illegal abortions cause up to 15 percent of all maternal deaths �and form the largest and single most alarming indicator of the present inadequacy of reproductive health services� (Ministry of Women Development and Youth Affairs 1995: 31). Pakistan is signatory to the ICPD 1994 document that includes a condemnation of the danger unsafe abortions pose to women around the world but stops short of stating that it should be legalized. Pakistan also ratified the Convention on the Elimination of Discrimination Against Women (CEDAW) in March 1996, which states that the state shall ensure the equality of men and women in deciding freely and responsibly the number and spacing of their children.

Despite such international commitments, Pakistani law does not allow abortion unless it is for the purpose of saving the life of the woman or providing her necessary medical treatment.7 A similar law exists in Bangladesh, although the government allows for induced abortion under the guise of �menstrual regulation� up to 10 weeks after a woman�s last menstrual period. India, however, has a more liberal abortion law, allowing women to have induced abortions for social and socialmedical reasons, although implementation of this law has not yet resulted in safe abortion services for all women.

Women�s groups, along with legal experts, have demanded that abortion laws be made more flexible ever since the 1976 Report of the Pakistan Women�s Rights Committee, which listed the recommendations of a high-level government committee of experts on women�s issues. The last Inquiry Commission on Women published its findings in August 1997, stating categorically that induced abortion in the first trimester must be made legal so as to avoid the serious social and public health costs for women undergoing unsafe illegal abortions.

The prevalence of induced abortion is difficult to determine with any accuracy because research into the practice has been limited, and there is an understandable reluctance among the public to admit to illegal activity when questioned. The rate of induced abortions in a Karachi community-based study was 12 percent out of 283 pregnancies reported by 34 women. (Fikree et al. 1996) Medical practitioners often informally share the opinion that more than half of the work of gynecologists in hospitals is the treatment of complications caused by induced abortions, although women are reluctant to admit that they sought a back-street abortion. (Rana 1992; Khan et al. 1996) The risks and exploitation experienced by women who seek an illegal abortion have been the subject of a number of press articles over the years and a limited amount of in-depth discussions among women�s groups. (Shirkat Gah 1996)

The social and religious taboos and legal restrictions on the practice inhibit the ability of organizations to delve into the problem more fully. But small-scale community studies and hospital-based surveys do exist, and their findings continue to be disturbing. In a follow-up of the Fikree et al. (1996) study in other settlements, it was found that those seeking abortion are generally married, young, illiterate, and have an average of 3.7 living children. In a study of three squatter settlements in Karachi, the 100 women who reported an induced abortion in recent years were more likely to be educated, between the ages of 26-35, and have had more than 4 pregnancies. (Saleem 1998) The context in which the decision to terminate a pregnancy took place included the initial problem of contraceptive failure or an unwilling husband, combined with children born too often and with too little spacing for the mother to handle. Doctors were most commonly asked to conduct the abortion. Patients rated dilatation and curettage as the most successful method. Fikree et al. (1996) also found that women sought induced abortion mainly for economic reasons or because of short pregnancy intervals.

In a hospital-based study in Karachi two groups of women were studied in 1977-78 and 1990-91. (Zaidi et al. 1993) Out of a total of 3,462 women, 81 (2 percent) gave a history of induced abortion. Although data for women under age 20 is not analyzed separately, it is revealing that 34 of these women were aged 15-25, 9 had no children, 35 had 1-4 children, and five were unmarried. Such findings establish that younger women, including those who are not married and those with less than 4 children, do seek abortions.

In Lahore, a study of 125 abortion cases found that 20 percent were between ages 15-19 and 10 percent of the women were unmarried. (Rana 1992) Although most of the induced abortions took place among older women (aged 30-40) who were grand multipara and belonged to a lower socioeconomic group, this study establishes clearly that adolescents in Pakistan are seeking abortions. The findings of a Karachi hospital-based study of 37 cases of induced abortion are similar. (Tayyab and Samad 1996) Over 78 percent were among women aged 25-34 and over 75 percent of all cases were multiparous. But with 6 of the patients between ages 15-24, and 3 with no previous children, once again the data suggest a small but potentially significant adolescent component to the induced abortion problem. Mensch et al. (1998) in their discussion of adolescent girls in the developing world note that adolescents may be over-represented in studies such as these because of the increased risk among younger abortion patients of sepsis and other related complications, caused possibly by delays in seeking medical care. This makes it difficult to correctly estimate the proportion of adolescent abortion patients.

These hospital-based studies reveal that the consequences of induced abortion are severe and often result in death. In Zaidi et al. (1993) the patients presented with a range of problems including trauma to their pelvic organs/bowels, vaginal bleeding, and sepsis. Over half of them had their abortions induced by a dai (traditional birth attendant) and a total of 13 women died in hospital. Eighty percent of the cases in the Rana report (1992) were for perforation of the uterus, and 12 percent died. Out of the 37 cases discussed in Tayyab and Samad (1996), nine died, with the rest reporting trauma, haemorrhage, and sepsis. Such findings contrast sharply with the lower mortality rates in developed countries where abortions are legal and the procedure is safer than pregnancy or childbirth; for example, in the United States the mortality rate associated with legal abortions between 1980-1985 was 0.6 per 100,000. (Henshaw and Morrow 1990)

For those women, and adolescents, who seek medical care after an induced abortion, there are few options other than large urban hospitals. Family welfare clinics do not treat abortion complications, and in fact lack any surgical facilities. The scarcity of medical services in the rural areas means that an undetermined number of women never access medical treatment for abortion-related complications. The difficulties of accessing urban-based services will be even greater for adolescent girls, most obviously unmarried ones, whose decisionmaking power and physical mobility is so restricted by their social environment that seeking any medical help outside of the village is fraught with barriers. (Khan 1998)

A few nongovernmental organizations have begun to offer treatment for postabortion complications. Marie Stopes Services (MSS) in Pakistan pioneered this work, and the Family Planning Association of Pakistan and Behbud Welfare Association have recently equipped some of their urban centers across the country to perform simple dilatation and curettage and provide other treatments for complications. These services are provided in addition to a range of traditional family planning services and also include tubal ligations and vasectomies. Although the largest client demand at MSS, for example, is for tubal ligations and injectables, there is a consistent stream of clients presenting with incomplete abortion. MSS estimates that 15-20 percent of their clients are adolescents, who are presumed to be married.