Instead of building the Taj Mahal, wryly remarked one gynaecologist, Emperor Shah Jahan should have spent that money on 14 maternity homes. After all, his beloved wife, Mumtaz Mahal, died giving birth to their fourteenth child.
We can forgive the ob-gyn crowd for seeing history through the lens of maternal mortality rates. They are a passionate crowd, inured to, but intolerant of, the suffering of their patients who arrive disembowelled and raging with fevers due to botched abortions.
The Taj Mahal quip was just an indication of how light the mood was in the room. The experts who work tirelessly to improve the health of mothers in Pakistan had something to celebrate on Friday: the launch of a report comparing ten years of post-abortion care.
The Population Council, National Committee for Maternal and Neonatal Health (NCMNH), Guttmacher Institute and Research and Advocacy Fund came together to produce the 120-page ‘Post-Abortion Care in Pakistan: A national study’. They went to 266 public and private hospitals in 26 of Pakistan’s 114 districts and spoke to 102 health professionals.
The beauty of this report is that it takes stock of changes that have taken place since 2002 when they did another nationwide study on unwanted pregnancy and post-abortion complications. The old study was a popular one and its numbers were widely used by all kinds of public health groups. With this new 2012 study, the doggedly persistent people behind the research are happy that they now have data they can compare.
The biggest change they found is that the dangerous methods are fading out and abortion and post-abortion complication treatments are getting safer. The report says that in 2002, women were commonly using anti-malarial medication, or laminaria sticks (made of kelp), to induce abortion, among other things. Other strange techniques included heavy exercise or rigorous massage to the abdomen to make the pregnancy terminate.
Happily though, the clothes hangers and herbs are being replaced for abortions by the miraculous ten-rupee Misoprostol pill. These numbers are the most striking – its use went up from 11% in 2002 to 68% over ten years. The experts also discovered that fortunately Misoprostol was also used to treat complications after women had abortions, thereby saving many lives. Its use here was just two per cent in 2002 but has skyrocketed to an amazing 90% by 2012. Clearly the advocacy to use this safe method has worked. In fact, now fewer women are even needing surgery to fix abortions gone wrong. The methods are changing.
The study shows, however, that the invasive dilatation and curettage, popularly known the D&C, in which the uterus is scraped clean, is just as favoured by practitioners at public health facilities to treat post-abortion complications. It was 84% in 2002 and ten years later not much different at 89%.
What has not changed since 2002 is the type of woman who gets an abortion. Contrary to popular myth she is not a single, affluent teenager but usually married, over 30 years old, illiterate, with at least five children and living in the countryside. She is using abortion as a method of family planning. And her husband knows about it.
“The men are getting desperate,” remarked Dr Zeba Sathar of the Population Council, referring to her experience in Punjab where the teams found that husbands wanted to be educated about contraception just as badly. It is harder to earn enough for big families.
“If family planning were available, we would not be talking about this in so much detail,” added Dr Sadiqua Jaferey, president of the NCMNH.
Generally, for women in the countryside, if they decide to terminate a pregnancy, they will first try to take care of it at home. When that doesn’t work, they then turn to dais, lady health visitors (LHVs), nurses or doctors. The only problem is that nearly half of abortions performed by anyone who isn’t a doctor are thought to lead to complications. Compared to that, only one in ten abortions performed by a gynaecologist develops a problem, said the study.
And so the women bleed, or go into shock because of sepsis. Their in-laws recommend remedies like these cocktails: milk, fruit juices, mint infusions, cinnamon infusions, green tea, black tea, eggs, spinach and phaki, ground herbs, tamarind, pulses and nuts, crushed betel nut, cumin seeds, clarified butter, melon seeds. But obviously, none of them can stop a haemorrhage.
And so the saddest parts of the report are at the back where there are interviews of women who got sick. They can’t even get help on their own, for starters. “She has to take her husband’s permission for post-abortion care as she needed his consent at the time of abortion,” said one dai in Hafizabad. “A woman cannot go alone without her husband’s permission.” Some women circumvent this by taking a child along, as they cannot be seen leaving the house alone.
A lady health visitor in Hafizabad told the researchers that some patients had to walk up to three miles just to reach them because there were buses in Kolo Tarar but not in the smaller villages. It was the same story in Khanewal and Umerkot where women were interviewed. One lady health visitor said that sometimes the ill women have to leave their children at home, locking them in the house if there is no one to babysit them while they go see a doctor.
A 30-year-old woman with five children in Karachi asked her husband for money to go see a doctor when she got sick after an abortion for her sixth pregnancy. “What he gives me is spent entirely on the children’s expenses and rent for the house,” she said. “So I had to bear the complications without treatment.”
And then there was a 32-year-old woman in Hafizabad who already had nine children. When she got pregnant for the 10th time and had an abortion, she developed an infection. “I tried to manage… at home by just having kehva and boiled egg because I could not afford to have milk, soup or meat,” she said. “Then I sold my fan and went to a doctor.”
The cruellest of blows comes when a poor woman manages somehow to scrape together the money to make it to a health care provider only to be mistreated at their clinic. Out of a sample of 102 health care professionals interviewed, nearly one-third were of the opinion that providers were reluctant to treat such patients.
The study states that women in the Punjab turned up the most for abortion-induced problems. In 2012, 400,000 of them sought treatment compared to the lowest in Balochistan at 47,000. And while there may not be a direct link, it is interesting to note that one local condom company said that its sales in Punjab beat even those in Karachi. “Central Punjab, Lahore, Gujranwala, Sialkot have much higher sales,” said Husain Karrar, the business unit manager of Biogenics Pakistan Pvt that sells the Hamdam condom at Rs25 for a pack of three. They also get orders from remote towns such as Uch Sharif. The good news, though, is that, according to Karrar, demand for this type of contraception is being met by the industry. The average sales for Biogenics is roughly Rs30 million and that is a mere 7% of the market.
The study also helped the experts discover where women were going to seek treatment after abortions. The highest total number of cases was treated by small private hospitals and by rural health centres (RHCs). Also, it turned out that Sindh’s RHCs had the highest average annual caseload of women seeking post-abortion care. This is interesting because they are now being managed by the Peoples Primary Healthcare Initiative begun in Punjab.
The results of the study are testament to the tenacity of non-governmental organisations such as the Population Council and NCMNH. The 2012 report offers a robust and an excellent barometer of changes in maternal health and fortunately enough, it can be replicated ten years down the line because of the way it is designed.
A word of caution did, however, come from Dr Gul Rashida, one of the authors. She stressed that these numbers did not include the women who had died of post-abortion problems and went unreported. If in 2012 about 700,000 women turned up at hospitals after botched abortions, we can assume many, many more did not even make it.
Published in The Express Tribune, September 30th, 2013.