KARACHI, March 23 “What is your understanding of abortion?” asked Dr Laila Shah of 29 young lady health visitors (LHVs) from the Federally Administered Tribal Areas (Fata) and the NWFP.

LHVs are paramedics who have completed an 18-month, government-certified primary healthcare course and work in villages across Pakistan. This group of young women had come for a refresher course organised by an NGO providing “Choices in Reproductive Healthcare.”

This entailed raising awareness and providing accurate family planning information to women in their villages and countering the myths attached to available family planning methods. But more important, for this course, was to select from amongst the attendees those who were willing to carry out safe abortions.

The issue of abortion is as contentious as it is enmeshed in cultural and religious taboos. Observing the manner in which it was explored, particularly by women from some of the most conservative and least developed areas of the country, was absorbing.

“It's murder”, “I'd call it a sin”, “You people are into the money-making business”, and “You have a reputation for performing abortions” wrote the majority of the LHVs on slips of paper. They were responding anonymously so that they could write without the fear of being judged on their views. “Those performing abortions and those seeking them will never be forgiven by Islam”, “They are not Muslims”, “It's illegal” and “Abortion is usually sought by immoral women” were other responses.

There were some LHVs, however, who felt that if carried out to “save the life of a woman,” or if contraception methods had failed and the “married” woman was poor, abortion was permissible.

Yet not one of the health workers agreed to perform the procedure.

But that was before they saw Dr Shah's presentation, which included harrowing pictures of what became of women who attempted to have an unwanted pregnancy terminated with the help of untrained practitioners working in less than sanitary conditions.

The World Health Organisation (WHO) defines an unsafe abortion as “a procedure for terminating an unwanted pregnancy either by persons lacking the necessary skills or in an environment lacking the minimal medical standards, or both.”

According to the 2006 PRB report on unsafe abortion, 19 million unsafe abortions take place annually across the world. Of these, 18.4 million occur in developing countries. And of the 67,900 women who die as a result of unsafe abortions, 67,500 are from developing countries.

PRB is a Washington DC-based research organisation. It aims to inform and empower policymakers in developing countries and in the United States while formulating policies on population, health and environmental matters.

A question of attitude

Abortion is prohibited in Pakistan and can only be performed to save a woman's life, but the procedure is carried out nevertheless.

According to figures cited in the 2004 report 'Unwanted pregnancy and post-abortion complications in Pakistan', carried out over a two-year period on married couples by the Population Council of Pakistan, some 29 of every 1,000 Pakistani women of reproductive age seek to terminate pregnancies through unsafe means. An estimated 890,000 such abortions occur annually in the country.

A number of factors lead women to resort to unsafe abortion, including the need for secrecy, the facts that access to safe abortion is restricted by law and that healthcare providers are less willing to provide this service, and the high cost of the procedure in private facilities.

Dr Shershah Syed, who heads the obstetrics and gynaecological ward at the government-owned Qatar General Hospital, believes that unsafe abortion is one of the major causes of maternal mortality and morbidity in Pakistan. “Abortion and spontaneous miscarriages account for 50 per cent of all gynaecological emergency admissions,” he said.

“It's like a plane-load of women dying every day while giving birth, and yet they fail to make news,” commented Dr Shah as she concluded her presentation.

“[The problem lies] in our own barriers,” acknowledged Dr Syed, “because the law is far more liberal than our practice.”

These barriers, he said, stem from ignorance of the law, religion and the disapproval with which society looks upon what are disparagingly called “abortionists”.

A study entitled 'Attitudes of Health Care Providers to Induced Abortion in Pakistan' provides a glimpse into the mindset of health providers. Published in the July 2003 edition of the Journal of the Pakistan Medical Association, the study is based on interviews of 141 medical practitioners from Lahore, Karachi and Peshawar.

All those interviewed were aware of the abortion laws of the country. While half of those interviewed (46.5 per cent) did not think there was any need to change the laws, 37.5 per cent wanted them changed. Of the latter, 80.9 per cent thought the laws were too liberal, and just a fraction wanted liberalisation in the country's abortion law.

Although abortion is included in formal residency training in Pakistan, the study found that only 25 per cent of the physicians had a favourable attitude towards induced abortion. Among the 67.3 per cent who had an unfavourable attitude, many wanted that a criminal case be registered against those who perform the procedure.

Legal ambiguities

Part of the problem lies in the ambiguity in the law. According to Section 338 of the Pakistan Penal Code, “Whoever causes a woman with child whose organs have not been formed, to miscarry, if such miscarriage is not caused in good faith for the purpose of saving the life of the woman or providing necessary treatment to her, is said to cause 'Isqat-i-Haml' [abortion] and the punishment is three years if the abortion is performed by the woman's consent, otherwise a maximum of ten years.”

Supporters of abortion say that this makes it quite clear that abortion in the earlier stage of pregnancy, which is 120 days (before 'ensoulment'), is not a crime if it is carried out to provide “necessary treatment”. They believe the term can be used to effectively counter any legal threats faced by health practitioners.

But according to Dr Syed, a full interpretation of saving a woman's life would mean saving her from emotional, physical and psychological stresses; all three play major roles in an unwanted pregnancy.

Prof Akmal Wasim of the Hamdard University, meanwhile, finds Section 338 “contradictory in its physiology.”

“It becomes ambiguous when we read this section where in one instance 'or providing necessary treatment' would be read in conjunction with the carrying out of Isqat-e-Haml 'in good faith for the purpose of saving the life of the woman',” commented the professor of law. “Or does the former provide a separate and independent ground for Isqat-e-Haml?”

“The question that arises here is why did the framers of the law use the particular terminology of “providing necessary treatment” since the first part is quite comprehensive and does not require any further elaboration,” said Professor Wasim. “Therefore, the question of the interpretation of the term “or” makes the “Isqat-e-Haml” legal if the phrase “necessary treatment” is interpreted as a separate and independent ground and therefore not liable for punishment prescribed in Section 338-A.”

According to the professor, the interpretation of statutes is always amenable to change. This, he believes, is one of the characteristics that make the law organic and responsive to the social requirements. “We must also bear in mind that Section 338 of the PPC was, in its original form, legislated in 1860,” he explained. “The law was enacted by the British, at a time when Victorian social values formed the norms of the society.” He also quoted The Women Commission Report 1997 to show that “Isqat-e-Haml” within the 120-day period has been validated in Muslim Jurisprudence by many authentic authorities.

Hope for future

After the conclusion of Dr Shah's presentation, there was a volley of questions and comments from the young paramedics - but most had already found their answers. “The cobwebs of doubt about carrying out abortion have been cleared”, commented one young LHV, and “It's the first time I learned that the procedure is not illegal,” said another. “I think that what I've learnt today is not to be judgmental; my foremost duty should be to save lives. If I turn a woman away, she may get the job done anyway but end up disabled like the women we just saw.”

Meanwhile, a three-year study to measure the economic cost of unsafe abortions-related morbidity and mortality is also under way, undertaken by the Collective for Social Science Research, a Karachi-based organisation that carries out academic researches. Their lead researcher, Ayesha Khan, explained that “There are scores of questions to which we will try and find answers, and measure the direct cost of the value of a woman and the cost of her death or illness; the cost of unsafe abortion as opposed to the alternative (including contraception, safe abortion, taking the baby to term etc); the costing of morbidity, and the burden of disability [that will include the average length of stay in the hospital].”

The aim, she says, is to find an answer to how unsafe abortion deepens the vulnerability and poverty of women and their families. “This will help initiate a policy debate with the authorities and induce them to bring about changes in the public health system,” she explained.