Why does Pakistan have low contraception and high abortion rates?

Stringent abortion laws and the taboos associated with the practice often lead women to seek out unsafe methods.
Published September 26, 2017

Thirty-six year old Sadaf Saeed, mother of a toddler was both “relieved and saddened” by the “extreme step” of terminating her pregnancy.

She was on the pill, as she was not planning on having a second child and therefore completely devastated after she found out she was pregnant. “We were at a complete loss,” she admitted.

The “decision” was the “most difficult” Saeed said and hopes “I hope I don't ever have to do this again,” she said.

And so before she left the clinic where she got her abortion carried out, she had an implant — a thin rod the size of a matchstick — inserted under the skin of her upper arm. The other long acting reversible contraceptive (LARC) method is the intrauterine contraceptive device (IUCD) both considered to be 20 times more effective than the pill, last several years and are reversible.

Every month, on an average between 10 and 15 women come to the same clinic that Saeed went to, in the heart of Karachi, seeking abortion in a safe environment, at the hands of trained healthcare providers.

“What is even more unfortunate is that a large number of the female clients are the same old faces who come for repeated abortions but stubbornly refuse to take the simpler and more cost-effective birth control route, we offer”

“We get call girls, domestic workers who have been impregnated either by the male help or some male member of the family, girls who have been raped, but more than them, a vast majority are married women who do not want to have any more children,” said one of the nurses who has been working there for the past five years. She has six kids but after joining the clinic she too, is taking the pill.

“What is even more unfortunate is that a large number of the female clients are the same old faces who come for repeated abortions, but stubbornly refuse to take the simpler and more cost-effective birth control route we offer,” said the nurse. Their main objection against family planning (FP), she said, was the weight gain that will occur.

According to the recent Pakistan Demographic and Health Survey (2012-13), even when women (26 percent) do use an FP method they discontinue and the rate is shockingly high at 37pc, and within 12 months of their initiation. Ten percent of episodes of discontinuation occurred because the woman experienced side effects or had health concerns.

Little wonder then that in Pakistan 48pc of pregnancies are unintended, of which 54 pc are terminated in an unsafe way.

Ethical and religious dilemmas by healthcare providers, an unresolved moral battle raging in the mind of the woman seeking termination makes the decision to terminate pregnancy very difficult.

“Fears about confidentiality, stigma, not knowing the law, expenses and most importantly because public hospitals don't entertain these clients,” are some reasons why women continue to seek abortions by unskilled providers said Dr Laila Shah, director of the Sukh Initiative at Jhpiego, which is promoting LARC in 42 public health facility hospitals in four towns of Karachi.

But, along with these very real concerns are the myths around contraception that continue to brainwash the women. “On several occasions, women have told me that they do not want the IUCD (or challa as it's known locally), inserted as it will go up their stomach, liver, or even brain.” We're just not able to overcome this fear from them,” she said while acknowledging that in olden times, the device, if inserted by an untrained provider, may have perforated the uterus and caused a complication.

Every year in Pakistan 9,700 mothers die according to UNICEF. “Based on global estimates, over 1,200 or 13pc are estimated to be attributable to unsafe abortions,” said Dr Agha Xaher Gul, heading the business strategy unit at Marie Stopes Society, fearing they may be much higher.

The complication rate due to an unsafe abortion is also quite high, since 68pc are conducted by a dai (traditional birth attendant), 49pc by lady health visitor as opposed to just 10pc by a gynaecologist.

What is sadder still is that each and every death and injury, as a result of unsafe abortion, is preventable through the provision of safe abortion services.

In addition, a lack of awareness and knowledge of the law and fear of backlash from extreme right has made talking about, as well as seeking safe abortion more difficult.

But those who are working on women's reproductive health and rights insist neither laws nor policies to prevent access to abortion can act as a deterrent for women seeking abortion. If it doesn’t happen in a health facility by a trained provider, it’ll happen elsewhere and perhaps unsafely, they say.

“And these will only increase the incidence of unsafe abortions which may cause higher incidence of injury and in some cases, death,” said Dr Sadiah Ahsan Pal, consultant obstetrician and gynecologist in Karachi.

At the same time, she said, it has not been proven that countries where abortions are permitted, the rate of abortion has increased. “They just reduce the number of unsafe abortions,” said Pal.

Pakistan's laws on abortion

While Pakistan is not among those countries which lets women make this decision on her body, the abortion laws give women as well as the providers certain leeway.

“There is no specific legislation for abortion,” explained Sara Malkani, a Karachi-based lawyer, adding that Article 338 “criminalises” abortion (with important exceptions) with a penalty for both the woman seeking an abortion and the provider who carries it out. “It also does not allow abortion on grounds of rape or in case of fetal impairment.”

According to Article 338 of the Pakistani 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,” it's said to cause 'Isqat-i-haml'.

A pregnant woman who caused herself to miscarry also commits the 'Isqat-i-haml' crime, which will be punished under Article 338-A which states: “Whoever causes isqat-i-haml shall be liable to punishment as ta'zir:

(a) With imprisonment of either description for a term which may extend to three years, if isqat-i-haml is caused with the consent of the woman.

(b) With imprisonment of either description for a term which may extend to ten years, if isqat-i-haml is caused without the consent of the woman.”

However, Malkani said: “There is provision for abortion in the form of 'necessary treatment' for a pregnant woman if the pregnancy has not gone beyond 120 days and is a threat to her health.”

For years health providers have tried to unpack the term 'necessary treatment' and failed because it is inherently vague and there is no direction from courts. But many even see it remaining “cloudy” as an advantage to be used in favour of those seeking abortion or seeking a revision of the law.

“Who knows in today's time, someone may tweak it in such a way that whatever leeway women have with it, may be stricken away too,” said Pal.

Conceding, Malkani said she would define 'necessary treatment' to include “psychological and economic well being of that woman.”

However, “vagueness” can be problematic. “The danger is if the others view it conservatively,” she pointed out, adding it may not be good time to review the law.

And while she would rather Pakistan has a separate law for abortion that affords women reproductive rights and autonomy, even if that happens, she feared, like Pal that the legislative advocacy may bring the focus on the previous abortion law making some people “all riled up” and even bring to a halt the more positive work being done on the ground.

Nevertheless, Malkani said perhaps abortion and post abortion care law can be looked upon through the prism of human rights. “Denying women access to safe abortion services, was denying them their reproductive health rights and was clearly a gender-base discrimination,” she said and it could be viewed as such.

The Muslim Ummah's view

Pakistan calls itself an Islamic republic and the majority of Pakistanis consider themselves God fearing. Many have killed their countrymen on as little as mere suspicion of treading the satanic path.

In this land of contradictions, there are people who are (or appear to be) convinced that offsprings are a gift from God, the more the merrier and by shunning this reward they are being ungrateful.

Agreeing to the traditional methods of birth spacing (withdrawal and breastfeeding), they, however, look upon any modern method of birth control with contempt. They will tell you God has promised to provide for each one on this earth, and they need not worry on that account. Many among them also believe it is their duty to help multiply the Muslim ummah to be able to fight the infidels (who have come up with contraception and methods to cause infertility).

Today, for every square kilometre of the land, there are 240 Pakistanis. There is a sea of humans everywhere -- causing traffic congestion, mounds of garbage, overcrowding on buses, in schools, clinics and hospitals. The urban landscape has become unmanageable and therefore ungovernable. There never seems enough of public transport vehicles, underpasses, fuel, electricity, educational institutions or healthcare.

Pakistan's population was 32.5 million in 1951 (when it was the 14th most populous country) and increased over five-fold, reaching 184.5 million in 2012-13. The results from a new national census states that that the population has reached 207.7 million, making it the world’s fifth-most-populous country after China, India, the United States and Indonesia.

But whatever the figures may be and whatever they may mean, the bottom line is that many married women do not want more kids than they already have. Still they will not use birth control. In the last PDHS seven million women of reproductive age declared they did not want more children or wanted to space birth.

“Lack of family planning is not a health problem; it’s a social problem and a women’s rights problem, rooted in misogyny and systematic disempowerment of women.” — Dr Agha Xaher Gul

Today, more than ever before, women’s sexual and reproductive rights are under renewed attack, fuelled by religion and the conservative right wing. Dr Agha Xaher Gul of MSS blames the state which has failed to provide healthcare to its citizens, specially women. “It has failed to harness religious misinformation, and failed to empower its citizens to achieve their full potential,” he said adding: “Lack of family planning is not a health problem; it’s a social problem and a women’s rights problem, rooted in misogyny and systematic disempowerment of women.”

Pushed to the wall, those who accidentally conceive resort to terminating their pregnancy.

In Pakistan currently only 35pc couples are using any birth control method (it's called Contraceptive Prevalence Rate or CPR). It has made a commitment to raise this rate to 50pc by 2020, as decided at the FP2020 summit.

Dr Tauseef Ahmad, senior technical advisor with Pathfinder International's Pakistan office, remains sceptical of Pakistan being able to achieve its CPR target in the next three years.

“No way! Except for Sindh, no Costed Implementation Plan on Family Planning has been approved by any of the three provincial governments. Devolution has destroyed the national image and effort,” he said.

Gag Rule's impact on Pakistan

The Mexico City Policy, also known as the global gag rule reinstated by the Trump government, earlier in the year, aims at cutting US assistance to health organizations working on FP services including providing information, referrals, or services for legal abortion or advocating for access to abortion services in their own countries.

According to Gul, his organisation, the Marie Stopes Society, the “largest private sector grant recipient for provision of FP services in Pakistan was the worst affected by the cut after the five-year funding of $40 million by the USAID was cancelled in Sindh and Punjab.”

“MSS would have averted an additional 596 maternal deaths through provision of quality family planning services to nearly 900,000 additional women as well as averting some 700,000 unintended pregnancies.” — Dr Agha Xaher Gul

Doing a quick back of the envelope calculation, he said: “This means an estimated two million married women of reproductive age across lower Punjab and Sindh provinces have been deprived of FP services after we had to abruptly end our FP programme, where a brigade of over 300 franchised private providers (already providing health services in rural areas) were trained, equipped and providing FP services.”

Had the project not closed prematurely, Gul pointed out, MSS would have averted an additional 596 maternal deaths through provision of quality family planning services to nearly 900,000 additional women as well as averting some 700,000 unintended pregnancies.

Based on current estimates, Gul presumes it will result in an additional 125,000 induced abortions (both safe and unsafe) with an estimated 30pc (or 37,500) of them to be unsafe, performed by untrained dais and quacks over a two-year period, across Sindh and Punjab that could have potentially been prevented through FP.

Illustrations by Nabeel Ahmed.