Botched abortions and maternal mortality

BOTCHED ABORTIONS AND MATERNAL MORTALITY

Health Dept procrastinates, gets bullied by clerics

• Country unlikely to meet UN-MDG targets for curbing maternal mortality rates
• ‘Within moral bounds, abortion not outlawed in Islam’

By Urooj Zia (Pakistan Today, 26 December 2010)

KARACHI: While Pakistan has signed on to the UN’s Millenium Development Goals (MDG), laws denying women access to safe, legal abortions mean that the country will be unable to meet targets for curbing maternal mortality rates. This is proved by statistics available at the UN-MDG website and with the Sindh health department. The maternal mortality rate in 2005 in Pakistan was 320 out of every 100,000 women. Five years later, instead of going anywhere near decreasing it by 75 percent as per the millennium development goal for 2015, the country has managed to reduce maternal mortality only marginally to 276 per 100,000.

As things stand now, 314 women out of every 100,000 die every year in Sindh due to pregnancy-related complications; while for every maternal death, scores of other women suffer pregnancy-related injury, infection or disease, including long-term disabilities such as infertility and incontinence. Gathering data about the contribution of botched abortions to maternal mortality, however, is next to impossible, according to the health department’s MNCH Director Dr Sahib Jan. “For one, families will not report such a death for fear of legal implications. Secondly, only private hospitals or illegal back-alley shops provide abortion services unless a mother’s life is in danger. And none of these will honestly report that a woman died due to a botched abortion,” she said.

The Sindh health department, meanwhile, does not seem too concerned. Not only are surveys to determine maternal mortality rates conducted only once every 10 years, the fact that post-partum haemorrhage (PPH) – one of the many consequences of botched abortions – is the leading cause of maternal mortality in the province does not ring any alarm bells either. PPH, according to the official Sindh health department line, is the result of either anaemia or not getting the patient to a professional healthcare provider on time.

While the WHO defines maternal mortality as the death of a woman “while pregnant or within 42 days of termination of pregnancy… from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes”, a recent UN report seeks to define maternal mortality as a direct result of the violation of women’s basic human rights. According to the report, unsafe abortions rank third in the list of causes of maternal deaths worldwide, causing 13 percent of the reported fatalities. Moreover, many of the other causes — haemorrhage (25 percent), infection or sepsis (15 percent), pre-eclampsia and eclampsia (12 percent), and prolonged or obstructed labour (eight percent) — are also direct results of the lack of access to safe, legal prenatal and maternal healthcare. The assertion that a majority of maternal deaths and disabilities could be prevented through access to sufficient pre-partum and post-partum healthcare, meanwhile, is supported by the fact that maternal mortality has been eliminated almost completely in many countries which have long repealed laws against abortions.

Implications of outlawing abortions

While complications arising out of botched or back-alley abortions are relatively obvious, other, more long-term after-effects are yet to be logged. A number of organisations provide safe abortions in Sindh without asking too many questions, but many of the counselling staff at these places ‘seem untrained’ and are ‘more than willing to pass moral judgements on what should be considered a woman’s personal decision,’ according to patients who agreed to speak to Pakistan Today. Post-abortion counselling is also an unheard-of concept. “For one, the decision to abort one’s foetus is a big one; then dealing with feelings of grief, mingled with shame is just too much,” says Fareeha, who went through the procedure while six weeks pregnant. “Non-judgemental pre- and post-abortion counselling is a must.”

“Post-abortion care is the duty of every doctor. In fact, it can even be classified under the heading of ‘best practices’,” Dr Jan said. “Without going into the definition of legal or illegal practices, we can say, for instance, that manual vacuum aspiration (MVA) should be used instead of dilation and cutterage (D&C) for abortions. The former is relatively less risky. The RU-486 (‘abortion pill’) should absolutely not be used because if a woman starts haemorrhaging, who is going to look after her?”

Dr Jan added that no moves are currently underway to legalise abortions. “This is a big debate, and we live in a religious country. We can’t come out and demand the legalisation of abortions,” she said, adding that the debate did not fall under the purview of the provincial health department, even though maternal health did.

‘Within moral bounds, abortion not outlawed in Islam’

Religious edicts, however, are fairly open on the issue. A Mufti who spoke to Pakistan Today on the condition of anonymity for fear of what he referred to as ‘undue backlash’, said that while scholars from all schools of thought in Islam agree that abortion is forbidden after the first four months of pregnancy, Hanafi scholars permit abortion until the end of four months, likening the act to a “moral transgression” rather than a “crime”.

The Quran, he maintained, does not explicitly ban abortions either, including in verse 6:151, which speaks about not killing one’s children out of fear of poverty, but does not address the issue of the status of a foetus as a living being. As such, he said, in Islamic legal terminology, one would use the principle of ‘al-aham wal-muhim’ (more important versus less important) in deciding the case, allowing scholars to permit abortions up to day 40, and in some schools of thought, even up to day 120 of gestation. He added that within moral and religious bounds, a physical or mental health provider must always be considered a better authority than a religious scholar when dealing with individual cases.