Saida was living in a poor suburb of Karachi with her five children when she discovered she was pregnant. Since she did not want any more children, the 40-year-old asked a local, untrained birth attendant for help and was given a herbal concoction to drink. That night, Saida developed a fever and started bleeding. By the next day, she was dead due to complications from a botched abortion.
Saida is just one of the women who die every 30-40 minutes in Pakistan due to maternal health-related complications. Pakistan has a maternal mortality ratio of 276 per 100,000 live births, and complications of abortion constitute about 6 percent of this statistic (PDHS 2006-07).
Part of the problem, according to Rahal Saeed, a consultant for Shirkat Gah – a women’s rights organisation in Pakistan is that abortion is only permitted to save the life of the mother and to ‘provide necessary treatment’. Safer, cheaper methods for abortion-related services such as manual vacuum aspiration and the abortion pill, which are also recommended by the World Health Organisation, are not widely available. As a result, most women have to undergo dilation and curettage for abortion and post-abortion care, which is more expensive as well as invasive. In addition, healthcare providers are largely unaware of and are not trained in these methods.
“They are simple outpatient services. We can save the lives of thousands of women who do not need to die and who do not need to leave behind young children,” she said.
About 30 percent of Pakistani women of reproductive age use traditional or modern forms of contraception. However, as Shirkat Gah’s research shows a further 25 percent cannot access contraception even if they want to use it. Ms. Saeed added that there was a shortage of family planning facilities, leading to high numbers of unwanted pregnancies.
“The typical woman who goes for an abortion has five or more children, is in her late twenties or early thirties, and has completed her desired family size. She and her husband have not used birth control. She’s often taken by her husband for the abortion. It becomes a form of family planning,” she said.
Many myths surround contraception in Pakistan. Almost half of the women surveyed said they did not intend to use contraception due to concerns that it may affect their fertility. Widespread misconceptions include the belief that the contraceptive pill will cause infertility and that herbal concoctions will induce abortion.
Ms. Saeed said religion also played a major role in preventing people from using contraception in Pakistan, where women have an average of 4.1 children.
“A lot of people believe that the number of children you have should be decided by God,” she said. “We have incidents where women want to use contraception but are not allowed to by husbands or in-laws.” Another reason for large families is the preference for boys – many families will have multiple children in the hope for sons.
Ms. Saeed said in rural areas contraception was distributed by government clinics and door-to-door health workers, but the supply system was often inadequate. About 40 percent of women are without contraceptive cover, and the current system only reaches about 60 percent of women. If they cannot obtain contraception from the clinics, women must buy it at the more expensive market rate.
Ms. Saeed said the government needed to ensure that the clinics had adequate supplies and provided comprehensive information about contraception. Some initiatives are now being taken to provide training in manual vacuum aspiration and medical abortion for post abortion care, and the hope is that these affordable procedures will eventually become accessible to women across the country.
“We need to empower women to know that they should be making their own decisions about how many children they want to have,” she said.
The Shirkat Gah research is part of the International Conference on Population and Development +15 project, a monitoring and research project coordinated by the Asian-Pacific Resource and Research Centre for Women (ARROW) which assesses progress on women’s health in 12 countries. ARROW is a women’s regional NGO committed to promoting and protecting women’s health rights and needs, particularly in the area of women’s sexuality and reproductive health.