• Among currently married Pakistani women aged 15–49, the level of contraceptive use is low (30%) and unmet need for contraception is high (25%).*
• Because so many women who want to avoid pregnancy use no method of contraception, the prevalence of unintended pregnancy in the country is high. In 2006–2007, approximately one-fourth (24%) of all births were unplanned.
• Many women who experience an unintended pregnancy resort to induced abortion. In 2002, a nationwide study estimated that close to 900,000 unintended pregnancies were terminated, equivalent to a rate of 29 abortions per 1,000 women of reproductive age.
• The current law in Pakistan permits abortion to save a woman’s life as well as to provide “necessary treatment” early in pregnancy. Given the narrow legal grounds for abortion and the difficulties that both women and health care providers have in interpreting the law, women who need an abortion tend to resort to clandestine, unsafe procedures.
• According to the 2006–2007 Pakistan Demographic and Health Survey, the country’s maternal mortality rate was 276 maternal deaths per 100,000 live births, and 6% of all maternal deaths resulted from complications of unsafe abortion.The latter figure may be an underestimate, as the average for South Central Asia is 13%.
CLANDESTINE ABORTION IN PAKISTAN
• According to knowledgeable health professionals, women who are seeking clandestine abortions often obtain them from dais (traditional birth attendants) or midlevel providers such as Lady Health Visitors, nurses and midwives—and as a result often experience complications.
• The proportion of women thought to have complications from abortion procedures performed by traditional birth attendants ranges from 55% among nonpoor urban women to 68% among poor rural women.
• An estimated 41–49% of abortions performed by Lady Health Visitors, nurses and midwives are thought to result in complications, compared with just one in 10 abortions performed by gynecologists.
• In Pakistan, the cost of a first-trimester abortion has changed little since 2002 (after inflation is taken into account) and remains high. For example, in 2012, the cost was Rs. 2,000–3,000 (US$20–30) for first-trimester abortions performed by traditional birth attendants and Rs. 3,000–5,500 (US$30–55) for those done by Lady Health Visitors and nurse-midwives. The cost can be a substantial barrier, especially for poor women. As a result, poor women not only are more likely than better-off women to resort to inexpensive providers who use risky methods, but also are less likely to be able to afford medical care when they experience complications.
TREATING POSTABORTION COMPLICATIONS
• In 2012, almost 700,000 Pakistani women were treated for complications of abortion (either induced or spontaneous).
• Approximately 15 per 1,000 women of reproductive age are treated each year for complications of induced or spontaneous abortions.
• Rates of treatment are close to the national average in Punjab and Sindh provinces (16 per 1,000 women in each), lowest in Khyber Pakhtunkhwa (9 per 1,000) and highest in Balochistan (20 per 1000 women).
• In 2012, 62% of all women receiving postabortion care (429,000) were treated in the private sector, while 38% (267,000) were treated at public-sector facilities. Overall, public-sector facilities treated an average of 289 cases per facility that year—fewer than in 2002 (317). Private-sector facilities treated an average of 292 cases in 2012.
• Public teaching hospitals had the highest postabortion care caseloads—an average of 1,740 cases in 2012. Large private-sector facilities, on average, treated 917 patients, significantly more than public district headquarters hospitals (599) and private teaching hospitals (532) did.
• Women who develop postabortion complications usually seek treatment in the private sector if they can afford it. According to in-depth interviews with service providers, women fear being treated poorly by doctors and other staff in public facilities, and they believe that public facilities lack proper equipment and needed medicines.
QUALITY OF POSTABORTION CARE AND ACCESS TO CARE
• In 2012, the most common procedures Pakistani health facilities used to treat abortion complications were dilation and curettage (D&C), dilation and evacuation (D&E), and medication abortion. Overall, 59% were treated using D&C or D& E, and 29% with medication abortion.
• Half of women receiving postabortion care at public health facilities, and close to two-thirds of those receiving such care at private facilities, were treated by D&C or D&E. In both sectors, only a very small proportion of women (6%) were treated by vacuum aspiration, which is one of the methods that the World Health Organization (WHO) recommends for the treatment of complications of first-trimester abortion.
• Postabortion care was available at almost all Pakistani health facilities that took part in a 2012 national survey. However, the availability of key equipment and supplies varied. The majority (91%) of facilities reported having instruments for the provision of D&C. However, only 25% had manual vacuum aspiration (MVA) kits and 24% had electrical vacuum aspiration (EVA) kits. A greater proportion of private-sector facilities than of public-sector facilities reported having misoprostol available (89% vs. 54%).
• A high proportion of facilities in Pakistan lack 24-hour coverage by personnel essential for the treatment of severe abortion complications. Overall, 59% of facilities lacked 24-hour coverage by a gynecologist in 2012, and 41% lacked such coverage by an anesthetist.
• Although the majority of health facilities provided counseling on family planning services, experts estimate that only 49% of postabortion care patients leave the facility with a method.
• Almost all surveyed providers agreed that postabortion care can save a woman’s life and that it should be more widely available. However, 42% perceived providers as having negative attitudes towards clients receiving such care, and 35% believed that providers are hesitant to treat postabortion patients.
• Interviews with women indicate that cost is one of the greatest barriers women face when attempting to obtain postabortion care.
• There is a clear need for improving the quality of postabortion care and for scaling up the use of safer, WHO-recommended methods for postabortion care, such as MVA and medication abortion.
• Substantial gaps exist in the onsite provision of contraceptive methods and family planning counseling to postabortion patients. Improving the provision of family planning services would likely lower the number of unwanted pregnancies substantially and thus reduce the number of clandestine abortions and the complications and deaths that often result.
• Health facilities in both the public and private sectors need to be adequately equipped, especially with MVA/EVA kits, to enable them to provide the full range of postabortion care services.
• Protocols for the provision of postabortion care need to be developed and should be disseminated widely.
• Training in the provision of postabortion care should be standard for all levels of healthcare providers who are permitted to perform such services. This must include training in MVA techniques and the use of misoprostol.
For more information on unsafe abortion and postabortion care in Pakistan, see Sathar Z, Rashida G, Shah Z, Singh S & Woog V, Postabortion Care in Pakistan, In Brief, New York: Guttmacher Institute, 2013, No. 4 <http://www.guttmacher.org/pubs/IB-PAC-Pakistan.pdf>
This document is an output from a project funded by the UK Department for International Development (DFID) and the Australian Agency for International Development (AusAID) for the benefit of developing countries. The views expressed and information contained in it are not necessarily those of or endorsed by DFID, AusAID or the Maternal and Newborn Health Programme Research and Advocacy Fund (RAF), which can accept no responsibility or liability for such views, for completeness or accuracy of the information, or for any reliance placed on them.
*Preliminary results from the 2012–2013 Pakistan Demographic and Health Survey show that contraceptive prevalence has increased to 35%, a very slow rate of growth over the past six years (source: National Institute of Population Studies (NIPS) and MEASURE DHS, Pakistan Demographic and Health Survey 2012-13: Preliminary Report, Islamabad, Pakistan: NIPS and MEASURE DHS, 2013).