Life over death, death over life: abortion in Pakistan

ISLAMABAD:

“Fear, pressure, and pain of abortion were much more than giving birth to a child”, says Hareem, who had an induced abortion at a health care facility in Rawalpindi. Although it was her second baby, she had to abort her six-week-old pregnancy because of the baby’s abnormal growth. Recalling her experience of abortion, she says, “It was as though everything from inside me was being wrenched out in the form of blood and pieces. It took me weeks to recover physically and mentally.”

Hareem was treated in a quality health care facility, yet her recovery took weeks. That is why it is hard to imagine Safina’s experience who did not have access to a good and safe medical service and suffered the pain of abortion at the hands of an untrained midwife.

The 40-year-old recently died after getting an infection in her uterus. A midwife did the abortion at Safina’s home in the Tench Bhatta area of Rawalpindi. Safina didn’t want another baby as she already had four children.

According to Nabila Chaudhary, a cousin of the deceased, a midwife treated Safina, and during the abortion procedure, blood clots formed in her uterus. For removal of clots, the midwife treated her again, placing her safety at risk. Safina died within a few weeks of her abortion. “In traditional societies like Pakistan, women have an important role in running of family affairs, and if a woman's health is compromised, smooth running of the family is jeopardised,” says Nabila.

“Abortion is a very sensitive matter and needs special precautions, particularly during treatment. A woman's body lies open susceptible to every kind of virus, and even minor negligence can have critical consequences for the patient’s health,” says Dr Umme Habiba, a gynaecologist and obstetrician at Valley Clinic, Rawalpindi.

Pointing out the factors contributing to an increased rate of compromised abortions, health worker Ishrat explains, “Midwives are unaware of the importance of quality treatment procedures. They are not properly trained, and they apply abortion methods that they may have heard about from others. They [midwives] have setups in small rooms in their houses and handle abortion cases for a few thousand rupees. A midwife charges an estimated Rs4,000 to Rs5,000 per case. One can only imagine the quality of health care. Most midwives use polythene gloves and conduct abortion procedures in unhygienic conditions, putting their patients’ lives at great risk. An abortion procedure demands an environment that is cleansed of germs and viruses.”

Abortions are a growing practice in Pakistan, entailing various push and pull factors, according to health providers. One example is Nasreen*, an unmarried young woman from the Attock district. Whether it happened because of a relationship or rape, that is unclear, but Nasreen was a few weeks pregnant when her mother brought her for an abortion procedure, according to a lady health worker who spoke on condition of anonymity. The health worker told me that Nasreen’s mother visited her home and out of desperation, she requested an abortion. She could neither allow the pregnancy to advance, nor could share the matter with the male members of her family for fear of severe consequences that her daughter could face after the disclosure.

 

The health worker says that when abortion was refused due to Islamic and legal boundaries, the desperate mother started begging for the sake of her daughter’s life and her family’s dignity and respect. If the abortion was not done, the young woman could become a victim of “honour killing” or forced to live the rest of her life as a criminal.

As per the 2008 FIGO situation analysis of unsafe abortions and implications for Pakistan's reproductive healthcare system, extramarital pregnancy contributes 6.01 percent and socio-economic concerns 11.58 percent. According to the data I collected under the “Punjab Transparency and Right to Information Law 2013” from the DHQ Attock, the state health facility provided abortion treatments to 1,550 patients, between January 2018 to July 2022. However, none of these cases of abortions were related to rape, extramarital affairs, or socio-economic concerns. All the cases were taken on medical grounds such as incomplete abortion, missed abortion, fatal reasons for TOP (major anomalous babies) abruption, and heart disease.

Nasreen’s case is not unique. An increasing number of girls and women are victims of rape or have relationships, and they get themselves into complicated situations, mostly for no fault of their own, Mrs Shamim shares her observations as a maternal health provider. Similar observations are shared by other health providers working in private and public health facilities in the Rawalpindi Division.

Mrs Shamim says that when she established her maternity health care clinic two years ago, many women approached her to get illegal abortions, but she refused. She is convinced that the rate of illegal abortions is increasing, putting lives of girls and young women at risk due to post-abortion complications.

Dr Sewra Bukhari, head gynaecologist at the gynaecology department at DHQ Jhelum, says, “Many women, accompanied by their young pregnant daughters, visit my clinic, but we refuse to provide treatment because of legal and Islamic boundaries. Then they approach midwives who treat them in unhygienic conditions, causing post-abortion complications.”

Dr Bukhari says that the hospital provides abortion treatment facility but within legal parameters. Abortions of pregnancy resulting from rape or extramarital affairs are not performed. Rape cases are referred to the allied hospitals in Rawalpindi.

An activist for reproductive health of women from Rawalpindi's Satellite Town area, whilst claiming anonymity, says, “There are many health facilities, including ours, that provide abortion treatment in the city, but they cater to patients with critical health conditions in order to save their lives. Due to legal and religius limits, women desiring abortion are forced to approach backdoor health care providers, thus placing themselves at risk. Lack of awareness and unintended pregnancies are the two main factors. It is not just a matter of poverty, because we have provided treatment to highly qualified women with critical health conditions. Lack of awareness about family planning and self-medication are also key concerns.”

 

Maternity health workers point out that the number of females approaching backdoor abortion treatment providers is on increase. There are many health facilities that provide treatment for abortions but are unable to respond due to legal implications and religious boundaries.

Health worker Ishrat shares that state-run hospitals have designated medico-legal teams for handling cases of rape victims. However, due to complicated procedures and social taboos, victims and their families avoid coming forward. Only a limited number of cases are brought to hospitals. The rate of illegal abortions is high in girls of young age.

Dr Sewra Bukhari notes that the rate of abortion is on increase due to unplanned pregnancies, ignorance of family planning, and to some extent, extramarital affairs. Abortions by untrained midwives are increasing the maternal mortality rate in Pakistan.

According to the data I received under the Right to Information from the DHQ Jhelum, while hundreds of cases of abortions for medical reasons were reported, no illegal abortion was noted, from January 2018 to July 2022. Similar responses were received from other state-run medical establishments in the Rawalpindi Division.

Gynaecologist Dr Umme Habiba notes that the most concerning element is that a large number of abortion cases remain unreported due to legal complications. There is a visible increase being observed in illegal abortion cases. She is of the view that the relevant state authorities and the medical community are concerned about the increase in the number of illegal abortions that seriously compromisie the health of patients, resulting in an increased rate of maternal mortality in Pakistan. Urgent measures are required. Absence of family planning, religious boundaries, and society’s judgmental attitude towards women intending abortion force patients to risk their health and lives by resorting to compromised health facilities.

 

Health worker Ishrat that abortion is a very sensitive health matter and needs strict precautions; however, most midwives are not at all attentive to hygiene protocols.

In Pakistan, unsafe abortion is one of the leading causes of maternal mortality, impeding the country from achieving the target of the Millennium Development Goal five. Despite having certain liberties in law and religion, Pakistan has a relatively high prevalence of unsafe abortions. Unintended pregnancies, absence of family planning, ineffective use of contraceptive methods, unawareness about law, poverty, and growing social ills are the root causes for the rise in the number of women seeking abortions in Pakistan. Death, serious health complications, and long-term disabilities that result from unsafe procedures place an enormous burden on the nation’s health care system as well as on a woman and her families. Rape and other social ills are also on increase as per the medical experts dealing with abortion cases.

Pakistan’s Abortion Law

Section 338 of the Pakistan Penal Code (Act XLV of 1860) deals with the issue of abortion at the stage when limbs and organs of a foetus are not formed. It permits medically trained practitioners to carry out an abortion, in good faith, for the purpose of saving the life of a woman or providing necessary treatment to her. If, however, abortion is not performed in good faith, it shall be liable for punishment with imprisonment, which may extend to three or ten years, depending on a number of factors, for example, consent, no consent, or danger of mortality.

Section 338-B of the abortion law deals with miscarriage and abortion for woman with child whose limbs or organs are not formed. The litmus test is whether the procedure is carried out in good faith purely for medical reasons—saving the woman’s life or other pressing health related reasons. The section also deals with situations where a woman induces her own miscarriage. She will be liable to one-twentieth of diyat ( the Islamic injunction of financial compensation paid to a victim or heirs of a victim in cases of murder, bodily harm or property damage) if the child is born dead, and full diyat if the child is born alive but dies because of any act of the offender. Imprisonment will apply for a term that may extend to seven years. This section further states that if because of a of miscarriage any hurt is caused to a woman or she dies, the offender shall be liable for punishment.

Law’s Grey Areas

Pakistan Penal Code permits abortion only to save the life of a woman or to provide her with “necessary treatment.” Medical practitioners have discretion regarding what constitutes a necessary treatment and/or whether an abortion is required. There is anecdotal evidence to suggest that doctors may refuse to provide abortion services due to religious or personal beliefs or if they feel that society takes a dim view of their action or sees it as a bad omen.

The abortion law in Pakistan is a plethora of policies and laws that undercut women’s decision-making power and sexual autonomy, thus creating incredible hardships for women needing or wanting SRH services.

A senior lawyer, requesting not to be named due to the sensitivity of the issue, says that when we look around at social realities, it is clear that the present law was drafted on presumptions that abortion cases would only be of married women; however, the ground realities are different. The current abortion law addresses the case of husband and wife who have been living together, and if they don’t meet this criterion, they are deemed to be committing something wrong. The current social reality is entirely different, and laws do not correlate with or address today’s abortion-related challenges. A large number of rape and underage sexual violence cases are reported whereas the law is silent on such challenges. There is a need to amend the law for rape and child sexual abuse cases to protect victims and survivors.

The senior lawyer says that a rape victim had filed a petition in a court in Peshawar, pleading to be allowed to have an abortion but the court refused. Such things make a victim’s life hell in this conservative society. If she carries the baby full term, society will treat her like an outcast, and if she wants to abort someone’s crime, she is implicated under the law. This injustice should be addressed by providing an option of abortion for rape and underage sexual violence victims without criminalising them.

More questions are posed by the senior lawyer. If a rape victim is not allowed to abort the baby, who is liable for the cost of their up-bringing and other expenses? Who is responsible for the physical and mental health damage done to the victim who may experience anxiety, panic attacks and other mental and physical health issues? The existing law is completely silent on such things.

It is a bitter reality that the entire blame for a forced pregnancy is put on a woman. In certain cases, perpetrators have been punished by the law, but the burden of someone else's crime is on the victim's shoulders. There is an urgent need to review the law that clearly fails to address the consequences of sexual violence against women and underage children.

The World Health Organization guidelines clearly state that a victim of sexual violence should be given contraceptive pills, but in Pakistan no such mechanism is available at the state level to provide treatment to a victim of rape and sexual violence, says Dr Umme Habib.

Pakistan’s Global Commitments and Obligations

 

The International Conference on Population and Development’s Programme of Action requires Pakistan to recognize the reproductive rights of women. However, lack of access to legal abortion and clarity on what is considered “necessary treatment” denies women their rights and pushes them to seek unsafe or clandestine abortions. Pakistan is recommended to take specific measures to ensure that women do not seek unsafe medical procedures, review punitive laws that criminalise women seeking abortions, and provide access to quality health services for complications from unsafe abortions.

In 2007, in accordance with ICPD’s General Recommendation No 24 Article 12, Pakistan’s continued use of punitive measures for extramarital consensual sexual activity violates women’s right to be free from discrimination, thereby also violating obligations under CEDAW.

In its General Comment No 22 on the right to SRH services, the committee on economic, social and cultural rights stated that preventing unsafe abortions required all states, including Pakistan, to liberalize restrictive abortion laws; to guarantee women and girls access to safe abortion services and quality post-abortion care, including training of health care providers; and to respect the right of women to make autonomous decisions about their sexual and reproductive health.

UN guidelines for member states, including Pakistan, at the Sustainable Development Summit in September 2015 set 2030 Agenda for sustainable development, and agreed upon seventeen sustainable development goals (SDGs), which included ending of poverty, fighting inequality and injustice, and tackling climate change. Universal access to reproductive health and rights is one of the goals of SDG 5, designed to ensure universal access to sexual and reproductive rights. Sexual rights refer to a range of human rights relating to sexual and reproductive health (SRH) and gender equality. This includes issues such as comprehensive contraception, gender identity, safe and legal abortion, early and forced marriage, same-gender relationship, female genital mutilation, and rights of sex workers.

Point to Ponder

 

All the evidence points to lives and health of women being placed at a critical risk because of the inadequacies of the current legislation on rights of women to abortion. The current legal framework is too narrow and too restrictive for providers of health care and women seeking medical help for abortion for pregnancies forced upon them by growing violence in society against women. Currently, while a provision on medical grounds exist, there is no provision for women suffering the indignity of rape or underage girls coerced into sexual relations. There is an urgent need to review and upgrade legal framework to make it reflective of the societal conditions.

Government should establish a commission to review the law, in consultation with key stakeholders from legal, medical, and civil communities. Mechanisms should be devised to support victims of rape and sexual abuse regarding the risks of forced pregnancy so that maternal mortality rate can be controlled.

Hospitals should be trained to positively respond by making access to medical procedures easy, cost-effective, and responsive.

There is also an urgent need to raise awareness of family planning with mechanisms for advice and support.

The issue of economic bondage of women is a major factor behind their silence and acceptance of injustices against them. This malaise will only be addressed through improved access to quality education and economic opportunities. Despite some visible progress, gender discrimination remains rife.

Shazia Mehboob Tanoli is an investigative journalist based in Islamabad. She tweets @shizrehman. All information and facts provided are the sole responsibility of the writer.