Young Samia*, a mother of one, seemed to carry the weight of the world on her shoulders: surrounded in the everyday struggle of survival and a never-ending cycle of family crises, Samia discovered that she was pregnant. Despite running from pillar to post, she couldn’t find a doctor who could help. At last, she resorted to swallowing contraceptive pills, that too in abundance. The foetus was aborted, but then started heavy bleeding and severe abdominal pain. A midwife was soon involved. But Samia’s case worsened. She died a month later.

Samia isn’t the only one who used abortion as her primary and preferred means of family planning: 23-year-old Fatima Bibi, a mother of two who works as a maid in Karachi, also swallowed pills to abort an unwanted pregnancy. “Back in our village in interior Sindh, we were always told family planning is wrong, as children are a gift from Allah,” said Fatima. “My husband, Ejaz, and I obviously never resorted to family planning before. We had one child each year after marriage, and when I conceived for the third time, we realised we couldn’t afford another child at all. We aren’t rich, but we want to educate our children. Therefore, we decided to abort without telling anyone. My husband brought me some pills and it was done.”

Such is the plight of thousands of women and their families in Pakistan. According to ‘Post-Abortion Care in Pakistan: A National Study’ – an examination carried out by the Population Council and published in August 2013 – 14 pregnancies out of 100 end in induced abortions every year. The highest rates of aborted pregnancies are found in Balochistan, with 38 abortions per 1000 women. This is followed by Khyber Pakhtunkhwa with 37 per 1000, Sindh with 31, and Punjab with 25.

A review of the existing data on the subject, interviews and discussions with the local healthcare providers confirm that only 30 pc of Pakistani couples use contraceptives, while an alarming 46 pc of women avoid them actively despite being aware of family planning. Much of this is simply because families and women believe in prevalent myths, taking unplanned pregnancies as “God’s will.” When it comes to women’s will, 11 pc want to space births while 14 pc want to stop childbearing altogether. Further probing confirms it is fear and suspicion that restrains women from using contraception, who later resort to unsafe abortions unfortunately.

In Fatima’s case, she conceived a second time when her youngest one was only a year-old. She was breastfeeding her second child when the third was conceived. “At the time, we didn’t think any family planning method was needed,” she said.

Doctors argue that an alarmingly high percentage of undesirable pregnancies end in illegal abortions for two main reasons: first, a lack of awareness as well as an active disregard for contraception/family planning; and second, the unavailability of skilled healthcare providers to advocate and galvanise family planning. The second factor impacts healthcare in rural parts of the country, because of which unsafe abortions occur and maternal mortality rates increase.

“Family planning is about making informed decisions if and when a woman wants to conceive. A gap of at least two to three years helps the mother to recuperate, and reduces the infant mortality rate. As a result, babies tend to be healthier,” argued Dr Hyder Ali Khan, who works at the Department of Public Health and Community Medicine at Shaikh Zayed Hospital, Lahore.

Meanwhile, a research carried out by USAID states that 24 pc of women don’t have access to reasonable family planning services, which indicates they have an unmet need for contraception. In such cases, an unmet need is the main cause of unwanted pregnancies, eventually leading to unsafe abortions, typically performed by untrained midwives under unhygienic conditions.

Such a scenario positions healthcare workers as crucial players in raising awareness about family planning and making contraceptives available at reasonable costs. The expertise, attitude, body language and willingness of a skilled healthcare worker to provide assistance is of utmost importance, otherwise couples remain unconvinced. At times, repetitive counselling might be needed especially when males are reluctant in practicing family planning.

“Family planning helps a couple in managing their household better, strengthening their financial position, securing education for their children and evaluating the nature of their relationship. There are many modern and safe family planning methods available nowadays, and are easily accessible through healthcare workers,” Dr Hyder argued.

Lady health workers claim that getting the message across can often be very problematic. “Each health worker goes to as many as 200 houses a month in urban and rural districts, advocating family planning,” explained a lady health worker, speaking to Dawn on condition of anonymity. “We wear a smile, keep our body language positive and during our discussions encourage the couples to mutually decide about extending their family, removing their fears about contraception. We explain to them how important it is for the males to participate in family planning, that it can’t work without them.”

Name changed to protect privacy