Despite legal restrictions that limit women’s access to abortion, the incidence of the procedure in Pakistan is high, and the abortion rate has increased during the past decade.1 According to a recent national study, women in Pakistan had an estimated 2.25 million abortions in 2012, equivalent to an abortion rate of 50 abortions per 1,000 women of reproductive age—nearly double the rate estimated for 2002 (27 per 1,000). Low levels of contraceptive use have resulted in high levels of unintended pregnancy, and more than half of the estimated 4.2 million unintended pregnancies in 2012 ended in abortion.

The data come from two nationally representative surveys fielded in 2012 as part of the study—the Health Facilities Survey and the Health Professionals Survey—and from existing national data sets, including the 2012—2013 Pakistan Demographic and Health Survey. The Health Facilities Survey assessed Pakistan’s capacity to provide quality postabortion care and ascertained the number of women treated for postabortion complications. It included 266 facilities: all large public and private teaching hospitals and a sampling of smaller facilities. Researchers used a questionnaire adapted from a previous national abortion study, conducted in 2002, to maintain comparability between the studies; it was administered in face-to-face interviews with senior medical officials and providers working in obstetrics and gynecology departments. The Health Professionals Study focused on providers’, researchers’ and administrators’ perceptions of abortion provision (e.g., the types of providers women use and the likelihood of complications). Researchers interviewed 102 respondents, who were chosen on the basis of their knowledge of and experience with abortion. Both surveys were conducted in the country’s four major provinces (Baluchistan, Khyber Pakhtunkhwa, Punjab and Sindh), where more than 90% of the population of Pakistan resides.

The researchers applied the data to an established method for indirectly estimating abortion incidence in settings where the procedure is not reliably tracked and where induced abortions may be passed off as or mistaken for miscarriages. They first used weighted data from the Health Facilities Survey to estimate the number of women treated in a facility for complications of either miscarriage or induced abortion; in 2012, these women totaled 712,000. Reducing this number by the estimated number of women treated for miscarriage (calculated from data on the biological likelihood of miscarriage and the province-specific likelihood that women who have a miscarriage will obtain care in a facility), the researchers estimated that 623,000 women were treated in facilities for complications from induced abortion alone

This number, however, excludes women who did not obtain facility-based treatment for abortion complications (e.g., because they feared legal ramifications and social stigma) or who did not have complications at all. Using data from the Health Professionals Survey, the researchers estimated the proportion of women having induced abortions who obtain postabortion care from a facility (taking into account women’s wealth and place of residence, the type of abortion provider, the probability of complications and the probability that women with complications would seek medical care). For Pakistan overall, that proportion was estimated to be about 28%. By applying it to the estimated number of women obtaining medical care for induced abortion complications, the researchers calculated that 2.25 million women had induced abortions in 2012. They further estimated that 4.2 million of the nine million total pregnancies in Pakistan that year were unintended.

The national abortion rate for 2012 was 50 per 1,000 women aged 15–49; it ranged from 35 in Khyber Pakhtunkhwa to 60 in Baluchistan. A previous study reported an abortion rate of 27 per 1,000 in 2002, although that study did not include private facilities and thus likely underestimated abortion incidence. Private facilities accounted for 62% of postabortion care cases in 2012. Although no data on private-sector care are available from the earlier study, national surveys indicate that a large increase occurred between 2002 and 2012 in the proportion of births that take place in private-sector facilities, suggesting that a similar trend may have occurred for abortion. That, combined with the relatively small change in the complication treatment rate for public facilities (from 7.3 to 6.0 cases per 1,000 women aged 15–49), leads the researchers to conclude that the abortion rate likely “increased substantially” between 2002 and 2012.

Fifty-four percent of Pakistan’s 4.2 million unintended pregnancies ended in induced abortion in 2012, and another 34% (1.4 million) ended in unplanned births. While the unintended pregnancy rate varied little by province, the proportion ending in abortion was much higher in Sindh and Baluchistan (62%) than in Khyber Pakhtunkhwa (40%).

The researchers conclude that the apparent increase in the abortion rate, accompanied by the high level of unintended pregnancy, is consistent with the major changes in fertility and fertility preferences observed over the past decade. These figures, they add, indicate “the very high level of unmet need for contraception and the high level of unwanted childbearing” in Pakistan—and thus the “urgent” need “for policymakers and service providers is to improve access to quality contraceptive services.” They point out that despite the private sector’s large and expanding role in providing abortions, postabortion care and health care overall, it has yet to become a major provider of contraceptive services.—H. Ball

REFERENCE

1. Sathar Z et al., Induced abortions and unintended pregnancies in Pakistan, Studies in Family Planning, 2014, 45(4):471–491.