Perceptions of registered medical practitioners of Karachi, Pakistan regarding induced abortion
Date of Award
Master of Science in Health Policy & Management (MSc Health Policy & Mgmt)
Community Health Sciences
The World Health Organization estimates that each year 75 million unwanted pregnancies occur worldwide. Of the 75 million, 20 million end in unsafe abortion. Of these 20 million unsafe abortions, 19 million occur in developing countries and the remainder mostly in Eastern Europe. As a result of these unsafe abortions at least 80,000 women die each year and millions more develop serious complications. More than 99% of these associated morbidity and mortality occur in developing world. Law or religion prohibits abortion in many countries, Pakistan being one of the countries where legally, induced abortion is only allowed to save the life of the mother. As far as religion is concerned it has it's own restrictions and since Islam is a multisectoral religion, every sect have their own interpretations regarding this belief. As a result of all these factors clandestine abortions occur. Furthermore, perceptions of doctors regarding Induced Abortion also vary. This can be attributed to their marital status, fertility, religious background, years of practice and personal prejudices. The incidence of abortion in countries where the law remains restrictive is very difficult to estimate as in these countries women tend to seek back street abortions. Though Hospital-based information from these countries is available, it only represents the tip of an iceberg of the dire sequel attached with unsafe abortions Most of the data regarding Induced Abortion in Pakistan is hospital based, as only the complicated cases either get admitted or reaches the hospitals. Data collected from various obstetrics and gynecology departments of government and nongovernment hospitals has estimated 4.5 – 15% of hospital mortality amongst the admitted cases as being due to induced abortion. Another community-based study from settlements of Karachi shows that out of a total of 282 reported pregnancies, 11% ended in Induced Abortion. We conducted in-depth interviews of TBAs, midwives, nurses, M.B.B.S. Doctors, and consultants. Both the TBAs and midwives and for that matter even the nurses and M.B.B.S. Doctors felt that Induced Abortion is neither legal nor permitted by Islam but all felt that incase of incest services of IA should be provided. They all felt that in case of an abnormal baby it would be justifiable to provide the services but usually they were approached for either economic reasons or for out of wedlock pregnancies. All felt that legalizing IA would not solve the problem of back street abortions; it would only aggravate matters, as the unskilled providers would provide the services without any hesitation. As far as the consultants were concerned, all felt that IA is a reality we as health care providers cannot afford to ignore. The unanimous conclusion was that if service needed to be provided, a skilled provider in an appropriate setup should do it. To avoid complications even the TBAs felt that though it was wrong they would still guide the consumer to a centre where services are provided in a safe condition provided they felt that the consumer was adamant about going ahead with acquiring the services of IA. Besides the in depth interviews 350 pre-tested questionnaire were filled by the principle investigator and the data collectors regarding the Doctors' demographic profile, their perceptions with context to religion, their practice and experience and also the legal status of IA. Of the 350 doctors participating in the study, 60.6% were M.B.B.S. and 39.4% were postgraduate doctors. As far as perception, regarding induced abortion was concerned 38.6% thought of IA as termination of pregnancy other than medical reason, 33.1% thought of IA as termination of pregnancy for medical reasons. Coming to the medical complications of IA, most doctors cited perforation of uterus (76.6%) as the foremost complications followed by heavy bleeding per vagina (74.6 %) sepsis/shock (57.4%). All the doctors cited minimum of at least three medical complications of IA. The religious perception of doctors showed some very interesting results whereby 56.9% of doctors believed that their religion did not permit lA, as opposed to 43.1oh who believed that IA was permissible. Out of those who believed IA was permissible in the religious context, 51.1% also felt that it was permissible within 120 days as ensoulment occurs after 120 days. This religious knowledge was basically acquired from religious books or hearsay and media and newspaper contributing to very small number of participants. (12.6%) Most doctors felt that knowing more about religion would help them counsel and guide their patients better though some even cited that it would make them feel more confident about their decisions. (13.6%) Though 75.7% doctors said that they had been requested by the patients to provide services of lA and financial constrain was the foremost reason and around 54oh of the doctors commented that they would refer the patients to centre were services of IA were provided 84.7% would not give a written referral as opposed to 88.9% guiding the patients to appropriate centre. Rape and unmarried girls were on top of the list (94.8%) for reasons for which IA should be provided and, 45.3% of the providers felt that the doctors would provide the services of IA, in favor of mother's life. The reasons for not providing the services of IA were practically two equal response i.e. not permitted by religion was cited by 65.4% of cases and not legal being cited by 70.9% of cases. Though 82oh doctors felt that consumers asked for services of IA and 61.4oh felt the need for service provision of lA 55.4o/o cited IA should not be legalized, as it would give rise to out of wedlock pregnancies. Finally 57.4o/o of doctors felt that it was not right of doctors to provide the services of IA. In many countries, whether or not to provide induced abortion on request or for specified indications is a contentious issue. Countries with legal restrictions or limited access to safe reproductive health services must look beyond the cultural and or religious debate associated with induced abortion to the public health issues associated with induced abortion. Contraceptive information and accessibility to services are an important remedial strategy to help to reduce the high incidence of unwanted pregnancies. As IA is still a sensitive issue, policy makers need to keep in mind the background that governs and influences a doctor's decision. Considering the inhibitions and prejudices about Induced Abortion (as revealed through the study), probably it would be more appropriate to liberalize the issue instead of legalizing it. Ife need to use our media not to promote IA but to let the public know more about the ominous consequences of lA and the advantages of accessing family planning facilities. Liberalization of the law by, making IA permissible to be carried out in appropriate settings, by skilled providers until a certain specific period of gestation, and with a doctor's approval (if the grounds are fetal malformation, risk to woman's life, and in case of rape) needs to be considered further.
Ali, F. M. (2003). Perceptions of registered medical practitioners of Karachi, Pakistan regarding induced abortion (Unpublished doctoral thesis). Aga Khan University, Karachi, Pakistan.