Dawn interviews Dr Azra Ahsan, a consultant obstetrician and gynaecologist with decades of experience in dealing with various complications of pregnancy, including unsafe abortions. She serves as technical consultant at the National Committee for Maternal and Neonatal Health, in addition to her responsibilities as secretary-general of the Association for Mothers and Newborns. She is also the technical advisor at the International Pregnancy Advisory Services, Pakistan.

Is there a specific reproductive, social and demographic profile of women who come to you for treatment of post-abortion complications?

In Pakistan, the majority of women who seek abortions are married, in their 30s, and have four to five children. They use abortion as a method of family planning instead of using a regular, effective, medically-prescribed method. They shun regular family planning for various reasons including health concerns, fear of side effects, religious beliefs, etc. What amazes me is that the women who do not use family planning due to religious beliefs have no qualms about terminating a pregnancy. In my practice, a sizeable percentage of women give a previous history of terminating a pregnancy for one reason or another.

What are the various methods used to induce abortions, including self-induced abortions?

Unqualified abortion providers and women who self-induce abortions tend to use different and dangerous objects; these can include sharp instruments such as hairpins, knitting needles, herbs and laminaria tents to terminate unwanted pregnancies.

Instruments used for providing unsafe abortions are usually not sterilised, and hence become a source of introducing infections into the mother’s womb. When abortions are induced by using pills, the risk of infection is reduced.

What are the warning signs and symptoms that an abortion has gone wrong? What are the most common complications at the time of admission?

Women should suspect that things have gone awry after a spontaneous or induced abortion if they experience persistent and severe lower abdominal pain, fever, foul-smelling discharge, diarrhoea, nausea, or vomiting. If these symptoms develop, women should immediately seek professional help. Women who have been through a prior unsafe abortion usually present symptoms of heavy bleeding, infections or injuries to body organs such as the uterus or bowels.

What are the short- and long-term damages or disease sustained as a result of unsafe abortions? What factors increase the risk of maternal morbidity and mortality?

In the short-term, women can suffer severe haemorrhaging or contract an infection. These infections can either be localised, or spread to other pelvic organs, or distributed through the blood stream to the whole body. Overwhelming infections — if not treated early — can lead to septicaemia (infection spreading via the blood stream), multi-organ failure and even death. Injuries to organs, however, may require major surgical procedures, including hysterectomy (removal of the womb).

In the long-term, infections in the pelvis can simmer and cause chronic pelvic pain and even blockage of the tubes; this results in the inability of a woman to conceive. Delay in diagnosing and treating these complications can result in permanent damage to health and even prove fatal.

Do women have reason to fear harassment when seeking treatment for unsafe abortions? Does it cause them to delay seeking treatment and thereby compound complications?

Women absolutely do face discrimination when they present some history of induced abortion. Equally, being upfront and providing the correct history is crucial for correct management planning by healthcare providers.

Having said that, personal beliefs held by healthcare providers tend to impact the care they provide to women. At times, their personal beliefs do clash with their professional responsibilities. It therefore becomes essential to mould healthcare providers’ personal values so as to ensure that they can provide quality care with empathy.

How has the phenomenon of unsafe abortions evolved over the years in Pakistan?

Over the years, I have observed that the nature of complications arising from unsafe abortions has changed — earlier, there were more cases of life-threatening injuries, but now, the complications are less serious.

In the olden days, a number of women used to arrive with injuries such as perforation of the womb. Such injuries were usually inflicted by abortion-inducing instruments and devices that are used by unqualified persons. I have seen women with their guts hanging out of their bodies due to these grievous body injuries. These women required surgical interventions. Some of them managed to survive but most of them died.

Now, I notice that women usually report haemorrhage and infections. Even the infections caused by unsafe abortions have decreased in incidence and severity over the years, and I feel this is due to the growing awareness about the use of abortion medicine pills rather than relying on invasive procedures such as dilation and curettage (commonly referred to as D&C).

That isn’t to argue that D&C is not used. In fact, D&C is still the most common method employed in Pakistan, not just by practitioners in the non-formal health sector but also by trained healthcare providers. The World Health Organisation and other international health organisations recommend that D&C should be replaced by evacuation techniques such as manual vacuum aspiration (MVA) and electric vacuum aspiration, or by abortion medicine in the form of pills. But in Pakistan, these recommendations are often still denied.