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January 2013, Volume 63, Issue 1

Review Articles

Ray of hope: Opportunities for reducing unsafe abortions!

Shaneela Sadruddin Khowaja  ( School of Nursing, Community Health Sciences, Aga Khan University Hospital, Karachi. )
Aneeta Pasha  ( School of Nursing, Community Health Sciences, Aga Khan University Hospital, Karachi. )
Shamshad Begum  ( School of Nursing, Community Health Sciences, Aga Khan University Hospital, Karachi. )
Mehr-un-Nisa Mustafa  ( Postgraduate College of Nursing, Hayatabad, Peshawar. )

Abstract

Unsafe abortion is one of the leading causes of maternal mortality and morbidity which impede the nation in achieving the targets of MDG 5. In the developing world, it is estimated that 13% of all maternal deaths are due to unsafe abortions. Despite having certain liberty in the law and religion, Pakistan has a relatively high prevalence of unsafe abortion. Poverty, unintended pregnancies, ineffective use of contraceptive methods and unawareness about the law are the root causes for the rise in the number of women seeking abortions. Nonetheless, with all these opening points of having permission in the law and religion could direct us that if we just follow them we can reduce the number of unsafe and illegal abortions. Therefore, there is a strong interventions would be required in health and legal aspects, which would decrease maternal mortality and morbidity.
Keywords: Unsafe abortion, Maternal mortality, Religion, Pakistan.

Introduction

Maternal health is always being a subject of discussion and so, loss of a mother has a greater impact on individual families and societies at large. Therefore, fifth Millennium Development Goal (MDG) clearly emphasizes on the improvement in the maternal mortality with one of the target being reducing unsafe abortions.1 Despite of having mother\\\'s imperative role, the developing world achieving this target is challenging, given that it is estimated that 13% of all maternal deaths are due to unsafe abortions.2,3 More so, it is predicted that unless serious interventions are not undertaken, half a million women will die due to unsafe abortions by 2015.3 Likewise, Pakistan\\\'s scenario is not very different compared to other countries in the developing world. Evidence shows that in Pakistan, death due to unsafe abortion is one of the leading causes of maternal morbidity and mortality. Data from 2002 shows that in that year, nearly 200,000 women were hospitalized for abortion complications.4 According to National Health Survey of Pakistan the maternal mortality ratio (MMR) is 400 deaths per 100,000 live births.5 In this context, it is imperative that Pakistan undertakes drastic interventions if it is to meet the fifth MDG by 2015. In order to assess ways in which to target maternal well-being, this paper will focus specifically on abortion and aims to identify the gaps between the conceptual understandings of abortion with its ground challenges/realities.
Conceptual Perspectives in Relation to Abortion:
There are multiple overlapping concepts attached with the notion of abortion. Still today, abortion remains a complex and multi-faceted issue that, due to its sensitivity, causes and encounters several constant debates and arguments. However, the purpose of this review is not to generate the debate but is to way out the solutions to the ground reality in the light of the theoretical principles.
Religion is the focal point of opinion via people search for the answers to questions of existence, decease and morality.6 The basis of religion also sees the most vocal opposition to abortion, perhaps because each of these three (life, death and morality) coalesce into the abortion debate. In this perspective, each human life is being created by God. So how killing is permissible as each individual is God\\\'s property? In His Holy book Quran, killing of a person is clearly condemned by God as "Take not life which Allah has made sacred" (6:151).7 The Holy words give the interpretations of Quranic injunctions which guide the Muslim Ummah to believe that abortion is equivalent to killing a human. In against to abortion, Quranic verses also states, "Kill not your children for fear of want. We shall provide sustenance for them as well as for you. Verily killing of them is a great sin" (17:31).8 Moreover, there are schools of thought who do believe on the notion that that the foetus has not been called as "human" or a "person\\\' until the soul is breathed into it, as a hadith, a saying of Prophet Muhammad (PBUH) says:
(As regards to your creation), every one of you is collected in the womb of his mother for the first 40 days, and then he becomes a clot for another 40 days, and then a piece of flesh for another 40 days. Then Allah sends an angel to breathe the soul into his body.9
The above statement creates a point that initial 120 days of foetal development can be considered as biologic life and later period is called as human life.10 In Pakistan, 86% belong to Sunni Muslim Sect out of which mostly follow the Hanafi school thought, which allows abortions in the first four months period of pregnancy.11 This also provides permission to the Islamic believers who consider that abortion could be permissible with the consent of both parents in certain circumstances (when mother or baby\\\'s life is in danger) or at an early stage of pregnancy.6
In Pakistan the legal grounding of Pakistani law is based on Islamic injunctions. With regards to abortion, an amendment was made to the Pakistan Penal Code (PPC) in 1997, which was supposedly made in the light of the Quran and Sunnah.12 As a result of this amendment, abortion is allowed in the early stages of pregnancy not only to save the life of the woman, but also for providing "necessary treatment". This vague terminology allows for a wide interpretation (especially by health care providers) of what constitutes necessary treatment and has therefore widened legal permission for carrying out abortion in the early stages of pregnancy. However, very few have the awareness and understanding of this change.13
The above analysis clearly highlights the permissibility of having an abortion at a certain stage and in special circumstances. Despite having certain liberties in the law and religion, Pakistan has a relatively high prevalence of unsafe abortions. In order to improve Pakistan\\\'s MMR by reducing unsafe abortions, it is imperative to understand the key causes of abortions in Pakistan.
Ground realities in regard to abortion:
Every year, approximately 9 million women have no other choice than to have an unsafe abortion.14 A review of global, regional and national literature reveals that the common reasons for the rise in the number of women seeking termination of pregnancies, often in unsafe conditions are: poverty, unintended pregnancies, ineffective use of contraceptive methods, and unawareness about the law.
Poverty can be defined broadly as the denial of choice, opportunities and human dignity; women who die from unsafe abortion are denied all three.15 Unsafe abortion is a cause and consequence of poverty reported in 2006 as "Death and denial: unsafe abortion and poverty," by the International Planned Parenthood Federation (IPPF).14 In Pakistan, evidence shows that more than half the women who opted for an unsafe abortion were illiterate and belonged to the very poor socioeconomic groups.16 The IPPF report also demonstrates the links between women\\\'s low economic status and unintended pregnancy, lack of access to contraception and reproductive health care services, higher likelihood of obtaining an unsafe abortion and of dying as a result of pregnancy, childbirth, and unsafe abortion. It has also been assumed that women\\\'s lack of involvement in taking decisions could be the reason of accessing at safe abortion services.14 Most of these pregnancies end up in abortions and unintended births, which increase women\\\'s lives and health in great danger. A National Survey conducted in Pakistan found that "about 55 percent women aborted because they had the desired number of children, 54 percent could not afford another child, 25 percent had infant children and 22 percent suffered health problems."17
Moreover, usage of effective contraceptive methods is another area of concern. Unintended pregnancies occur because some 215 million women have an unmet need for contraception.18 Only 30% of married women of reproductive age use any contraceptive method; more than a quarter of these women use traditional methods, which are less effective than modern contraceptives.19 A lack of awareness about the law has also resulted in women opting for unsafe abortions at the hands of untrained health care providers. The study conducted from 2002 to 2004 found that pregnant women who wish to have an abortion in Pakistan often are forced to visit illegal clinics run by midwives, and 23% women who have abortions done by unskilled providers, are later hospitalized for complications.20 These women end up with complications such as sepsis, haemorrhage, uterine perforation, visceral injuries, or long term effects like infertility with its psychological effects.21,22 All the above results are significant in increasing maternal morbidity and mortality.
A review of the context in which poor Pakistani women live, shows that abortion is often an action they opt for in light of their socio-economic issues (such as poverty), lack of awareness about laws, and unwanted pregnancies resulting from the inadequate and unavailable usage of family planning methods.
Points to Think:
Pakistan, is a Muslim state, and under the Islamic perspective, strategies exist that can bridge the gap between the understandings of abortion with the present scenario. The amendment in the PPC can be considered an encouraging step towards saving women\\\'s lives since it uses a terminology that permits abortion "in the early stages of pregnancy not only to save the life of the woman, but also for providing necessary treatment" show the inherent and valuable flexibility of Islamic jurisprudence.6 Despite having the reformation in the law, almost all abortions take place illegally and in secrecy in Pakistan.5 Therefore, there is a need to provide solutions to women who for different reasons wish to abort and at the same time enact laws that would not contradict Islamic principles.6 Permissible aspects in the law should be accessible and available to every woman without having the threat of violence or societal pressures. It could be done by raising awareness about the legal aspect as a prime area of intervention for all adults.
In addition, the mentioned causes clearly highlight the root causes of unsafe abortion; however, it could be preventable by provision of, and access to, safe abortion services and care which can contribute significantly in achieving the MDG. Availability and accessibility of contraceptive services should be encouraged which can reduce the chances of unplanned and unintended pregnancies. Therefore, women should be educated and counseled about modern family planning methods with its proper use. A study concluded its\\\' results that the quality of family planning counseling should be improved with emphasis on effective use of a method, back-up support in case of method failure and on dire consequences of having unsafe abortions.23 Introduction of post abortion care (PAC) into routine health services has also been strongly advocated and promoted in order to reduce abortion-related morbidity and mortality and prevent further unwanted pregnancies.24
Furthermore, the importance of this issue is heightened because of the apparent differences that exist between the real conditions of life in these communities, and lack of understanding about jurisprudential principles.24 Health professionals\\\' unfavourable attitude towards abortion leads "to a major stumbling block to the development of better abortion related services".9 Community should also be informed about the health consequences and health risks attached to unskillful practices. Capacity building should be enhanced to all professionals especially health and legal background who are being involved and potential to be involved in this issue of abortion.
If the liberty in the law and religion are followed, the number of unsafe and illegal abortions can be reduced; thus decreasing maternal mortality and morbidity.

Conclusion

Unsafe abortion is one of the leading causes of maternal mortality and morbidity which impedes the nation in achieving the targets of MDG 5. Though, revision in the law under the principles of Islamic religion is a ray of hope, but certain root causes show Pakistan to be a country with high prevalence of unsafe abortion. Major interventions in health and legal aspects are therefore mandatory.

References

1. Barbara B, Crane E, Charlotte E, Hord S. Access to safe abortion: An essential strategy for achieving the millennium development goals to improve maternal health, promote gender equality, and reduce poverty. (Online) 2006 (Cited 2011 August 16). Available from URL: http://www.unmillenniumproject.org/documents/Crane_and_Hord-Smith-final.pdf.
2. World Bank. The Millennium Development Goals for Health: Rising to the Challenges. Washington, D.C. 2004; World Bank.
3. Sathar ZA, Singh S, Fikree FF. Estimating the incidence of abortion in Pakistan. Studies in Family Planning, 2007, 38: 11-22.
4. Abortion in Pakistan. In brief. (Online) 2009 (Cited 2011 August 16). Available from URL: http://www.guttmacher.org/pubs/IB_Abortion-in-Pakistan.pdf.
5. Pakistan Demographic Health Survey 2006. National Institute of Population. Studies Islamabad, 2002.
6. Aramesh, K. Abortion: An Islamic Ethical View. Iranian Journal of Allergy, Asthma and Immunology. (Online) 2007 (Cited 2011 August 1). Available from URL: http://iaari.hbi.ir/ journal/archive/articles/v6s5ar2.pdf
7. Quranic Versus (6:151).
8. Quranic Versus. (17:31).
9. Hadith No. 2643. Alamri YA. Islam & Abortion. Journal of the Indian Medical association. (Online) 2011 (Cited 2011 October 6). Available from URL: http://docs.google.com/viewer.
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11. Rehan, N. Attitudes of health care providers to induced abortion in Pakistan. J Pak Med Assoc 2003; 52: 293-6.
12. Pakistan. Population Policy Data Bank maintained by the Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat. (Online) (Cited 2011 August 16). Available from URL: http://docs.google.com/viewer?a=v&q=cache: 1rtCxkEySUYJ:www.un.org/esa/population/publications/abortion/doc/pakistan
13. Ahsan A, Jaferay SN. Unsafe abortion: global picture and situation in Pakistan. J Pak Med Assoc 2008; 88: 660-1.
14. Thomas, G. Death and Denial: Unsafe Abortion and Poverty. (Online) 2006 (Cited 2011 August 16). Available from URL: http://ippf.org/en/Resources/Reports-reviews/Death +and+Denial.htm
15. Ensuring Women\\\'s Access to Safe Abortion: A Key Strategy for Achieving Millennium Development Goals. (Online) 2011 (Cited 2011 August 16). Available from URL: http://www.ipas.org/ Publications/asset_upload_file557_2458.pdf
16. Shah N, Hossain N, Noonari M, Khan NH. Maternal mortality and morbidity of unsafe abortion in a university teaching hospital of Karachi, Pakistan. J Pak Med Assoc 2011; 61: 582-6.
17. National Institute of Population Studies (NIPS) and Macro International, Pakistan Demographic and Health Survey 2006-07, Islamabad, Pakistan: NIPS, 2008.
18. Cleland J, Bernstein S, Ezeh A, Faundes A, Glasier A, Innis JW. Family planning: The unfinished agenda. Lancet 2006; 368: 1810-27.
19. More Pakistan women prefer abortion to family planning. (Online) 2011 (Cited 2011 August 18). Available from URL: http://www.onepakistan.com/news/health/85918-more-pakistan-women-prefer-abortion-to-family-planning.html
20. Population Council, Unwanted Pregnancy and Post-Abortion Complications in Pakistan: Findings from a National Study, Islamabad, Pakistan: Population Council, 2004.
21. Bhutta S, Aziz S, Korejo R. Surgical complications following unsafe abortion. J Pak Med Assoc 2003; 53: 286-9.
22. Siddique S, Hafeez M. Demographic and clinical profile of patients with complicated unsafe abortion. J Pak Med Assoc 2007; 17: 203-6.
23. Saleem S, Fikree FF. Induced abortions in low socio-economic settlements of Karachi, Pakistan: rates and women\\\'s perspectives. J Pak Med Assoc 2001; 51: 275-9.
24. The impact of unsafe abortions on MDG 5: Improve maternal health. (Online) (Cited 2011 August 29). Available from URL: http://www.guardian.co.uk/journalismcompetition/2011-theme-maternal-health.

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