Both doctors and health workers in Pakistan seem to be solidly against abortion. But attempts to raise awareness do seem to yield some dividends, at some levels, as in the case of lady health visitors (LHVs) who participated in a workshop at Karachi recently.
LHVs are paramedics who have completed an 18-month, government-certified primary healthcare course and work in villages across Pakistan.
When the participants, drawn from the Federally Administered Tribal Areas (Fata) and the NWFP (regions considered as being under the thumb of Islamic fundamentalists) were asked, "What is your understanding of abortion," they described it as murder and worse.
"Those performing abortions and those seeking them will never be forgiven by Islam", "They are not Muslims", "It's illegal" and "Abortion is usually sought by immoral women." Such were the responses written on slips of paper,†during a refresher course organised by an NGO providing "Choices in Reproductive Healthcare."
There were some, however, who felt that if carried out to "save the life of a woman," or if contraception methods had failed and the "married" woman was poor, abortion was permissible.
Yet not one of the health workers agreed to perform the procedure.
It is not just paramedics, even fully qualified doctors do seem to be against the very idea of abortion.
A study entitled 'Attitudes of Health Care Providers to Induced Abortion in Pakistan' provides a glimpse into the mindset of health providers. Published in the July 2003 edition of the Journal of the Pakistan Medical Association, the study is based on interviews of 141 medical practitioners from Lahore, Karachi and Peshawar.
All those interviewed were aware of the abortion laws of the country. While half of those interviewed (46.5 per cent) did not think there was any need to change the laws, 37.5 per cent wanted them changed. Of the latter, 80.9 per cent thought the laws were too liberal, and just a fraction wanted liberalisation in the country's abortion law.
Although abortion is included in formal residency training in Pakistan, the study found that only 25 per cent of the physicians had a favourable attitude towards induced abortion. Among the 67.3 per cent who had an unfavourable attitude, many wanted that a criminal case be registered against those who perform the procedure.
In such circumstances, the recent workshop in Karachi was an attempt securing the help of the paramedics to raise awareness and providing accurate family planning information to women in their villages and countering the myths attached to available family planning methods. But more important, the idea behind the course was also to select from amongst the attendees those who were willing to carry out safe abortions.
A presentation by Dr Laila Shah seemed to make them think again, reports Zofeen T. Ebrahim for Dawn.
Shah's presentation included harrowing pictures of what became of women who attempted to have an unwanted pregnancy terminated with the help of untrained practitioners working in less than sanitary conditions.
According to a report by the Washington-based Population Reference Bureau (PRB) unsafe abortion, 19 million unsafe abortions take place annually across the world. Of these, 18.4 million occur in developing countries. And of the 67,900 women who die as a result of unsafe abortions, 67,500 are from developing countries.
Also according to figures cited in the 2004 report 'Unwanted pregnancy and post-abortion complications in Pakistan', carried out over a two-year period on married couples by the Population Council of Pakistan, some 29 of every 1,000 Pakistani women of reproductive age seek to terminate pregnancies through unsafe means. An estimated 890,000 such abortions occur annually in the country.
A number of factors lead women to resort to unsafe abortion, including the need for secrecy, the facts that access to safe abortion is restricted by law and that healthcare providers are less willing to provide this service, and the high cost of the procedure in private facilities.
Dr Shershah Syed, who heads the obstetrics and gynaecological ward at the government-owned Qatar General Hospital, believes that unsafe abortion is one of the major causes of maternal mortality and morbidity in Pakistan. "Abortion and spontaneous miscarriages account for 50 per cent of all gynaecological emergency admissions," he said.
"It's like a plane-load of women dying every day while giving birth, and yet they fail to make news," commented Dr Shah as she concluded her presentation.
After the conclusion of Dr Shah's presentation, there was a volley of questions and comments from the young paramedics - but most had already found their answers. "The cobwebs of doubt about carrying out abortion have been cleared", commented one young LHV, and "It's the first time I learned that the procedure is not illegal," said another. "I think that what I've learnt today is not to be judgmental; my foremost duty should be to save lives. If I turn a woman away, she may get the job done anyway but end up disabled like the women we just saw."
Meanwhile, a three-year study to measure the economic cost of unsafe abortions-related morbidity and mortality is also under way, undertaken by the Collective for Social Science Research, a Karachi-based organisation that carries out academic researches. Their lead researcher, Ayesha Khan, explained that "There are scores of questions to which we will try and find answers, and measure the direct cost of the value of a woman and the cost of her death or illness; the cost of unsafe abortion as opposed to the alternative (including contraception, safe abortion, taking the baby to term etc); the costing of morbidity, and the burden of disability [that will include the average length of stay in the hospital]."
The aim, she says, is to find an answer to how unsafe abortion deepens the vulnerability and poverty of women and their families. "This will help initiate a policy debate with the authorities and induce them to bring about changes in the public health system," she explained.