Sadaf Khan ( Department of Community Health Sciences, Ziauddin Medical University, Karachi )
No other topic in the realm of maternal health is perhaps as controversial and probably none arouses such strong feelings as that of induced abortion. Involved are numerous issues going beyond the clinical and embracing social, political and behavioural dimensions. There is however an urgent need to separate emotional debate from facts to address this issue that claims many maternal lives each year and causes severe morbidity for others. Global estimates rank abortion as one of the five leading contributors to maternal mortality.1 Many potentially adverse health consequences are difficult to measure, so the health effects in terms of physical morbidity are not well documented. There is even less knowledge about the psychological, social, and economic consequences produced by induced abortion.
It is observed that in Pakistan an estimated 890,000 induced abortions occur annually.2 These may often be in unsafe conditions and at the hands of unskilled providers. Estimates by the World Health Organization indicate that 10-50% of women seeking unsafe abortions, need subsequent medical care.3 In the Asian region, the risk of a woman dying after unsafe abortion is as high as 1 in 250 compared to 1 in 1900 in Europe.4
There is a need to look "beyond the numbers" at the strategies that should be adopted to reduce not only the complications that arise from abortions but also the factors that give rise to the need for these abortions. The first step is formative research promoting a better understanding of background factors that lead to women opting for abortion as a method of fertility regulation. The article discussing potential risk factors for abortion in this issue is thus particularly relevant.
In Pakistan where only 27.6%5 of couples use some form of contraception and where the gap between the desire to space/limit births and contraception usage (33%)5 is one of the widest in the world, abortion is often the only choice for couples to deal with an unplanned and unwanted pregnancy. It is particularly significant that the above mentioned article identifies 40% of abortions as having occurred in current users of contraception and that post-abortion only half the women adopted some form of contraceptive method. There is thus the need to direct efforts both at "tertiary prevention" in terms of incorporating adequate family planning counseling and services into the Post Abortion Care set up as well as "primary" prevention by providing improved availability through adequate contraceptive services6 and counseling to prevent method failure and drop outs.
Providing couples a wide choice of contraceptive methods, including emergency contraception, available through multiple supply sources at affordable prices and ensuring that correct information about proper use is provided is critical. So is addressing concerns about side effects real and/or imagined. This will help minimize the risks that women undertake when they opt for an abortion to meet a need for contraception that is either unmet or inadequately met.
1. "Maternal Health Around the World" poster. World Health Organization and World Bank, 1997.
2. Population Council, Islamabad. Unwanted pregnancy and post-abortion complications in Pakistan: findings from a national study. Population Council, Islamabad, 2004.
3. Unsafe abortion - global and regional estimates of the incidence of unsafe abortion and associated mortality in 2000 - 4th edition. WHO, Geneva 2004.
4. Abortion: a tabulation of available information, 3rd edition. WHO, Geneva, 1998.
5. Pakistan Reproductive Health and Family Planning Survey 2000-1.
6. Billings DL, Benson J. Post abortion care in Latin America: policy and service recommendations from a decade of operations research. Health Policy Plan 2005;20:158-66.