To: Minister of Health of Gwader, Balochistan, Pakistan From: Lubna Jamal Abortion and Reproductive Health in Balochistan, Pakistan

Background The poverty, high illiteracy and increasing antagonism toward modernism has impacted womens reproductive health in Pakistan. An estimated 36 percent of the population continues to live below the poverty line and almost 50 percent are illiterate, including two-thirds of all women. Infant mortality rates are as high as 97 per 1,000 live births, and maternal mortality stands at about 600 deaths per 100,000 or 10,400 maternal deaths every year with 80 per cent of maternal mortality estimated as preventable (Ahmed, 1991). Moreover, there is a huge imbalance in these figures. In Balochistan, for instance, the maternal mortality is 785 deaths per 100,000 live births which is nearly triple the national rate. Overall, the rural maternal mortality is nearly twice than that in cities. The prevalence of contraceptive use is 30%. Only 50% of women received postnatal care after their last pregnancy. A little over a quarter of deliveries occur at home and 33% of pregnant women in Pakistan are anemic, half of which receive treatment from physicians and one-third of which receive no treatment at all. (Guttmacher.org/abortion) The overall situation in Pakistan is grim, with widespread socio-political and economic instability in recent years; amid rampant inflation and unemployment, a deteriorating security situation, and widening developmental disparities between rural and urban populations. Especially vulnerable are women living in kachi abadis, which are squatter settlements in Balochistan, Pakistan. Balochistans focus for many years has been on politics and not on reproductive health of women. This area of Pakistan is lagging far behind other cities in Pakistan. According to Free and Fair Election network, two-thirds of the 554 Basic Health Units (BHUs) run by the government in Balochistan do not have any female staff. There are 5,345 BHUs in the country, according to the government. (Baloch Hal, 2010) Almost one-fourth of monitored BHUs do not have personnel to offer family planning counseling or other services; almost 40 percent do not have a maternity kit; and almost half do not have a labor room. Of note are the geographical disparities across the country, especially between Punjab (with the most personnel and facilities to serve women) and Balochistan (with the least). (Baloch Hal, 2010) There are women living in Balochistan that will never see a womens health physician. (united nations, 1993) Reproductive Health Issues Lack of reproductive health services for women in Pakistan is a problem because of premature deaths due to lack preventative services. Abortion is one of the most common and controversial issue in many parts of the world. Pakistan is no different, but the politicians, religious leaders and health professionals have been slow to respond to the needs of countrys women; abortion remains a social taboo. Despite this, Pakistans abortion rate is a substantial 29 per 1,000 women

of reproductive age. (Medicalnews.org, 2005) Annually, approximately 890,000 abortions are performed with 14 of every 100 pregnancies ending in induced abortion. (Guttmacher.org/media 2005). Abortion rates appear to be substantially higher in the two more rural of Pakistans four provinces. In North West Frontier Province (NWFP), an estimated 37 abortions took place per 1,000 women aged 1549, and in Balochistan the rate was 38 per 1,000. By comparison, rates were lower in the two more urban provinces 25 in Punjab and 31 in Sindhwhere contraceptive use is somewhat higher. (Bongarts, 1993) Because it is almost impossible to obtain reliable data on induced abortion through direct interviews with women, these rate estimates derive from an established indirect method that uses health facility data on women treated for post abortion complications and experts estimates of the likelihood of hospitalization after abortion. Given the stigma and illegality of abortion in Pakistan, women themselves are very reluctant to admit to having had induced abortions, as they associate it with murder. As such clandestine abortions are not uncommon, resulting in disastrous consequences for those involved. A survey of 30 private and public hospitals in Pakistan estimated that 11% of maternal deaths were attributable to unsafe abortions. The number of living children that women already have when they decide to abort is quite high, and since Pakistani women want an average of 3.1 children, the women who seek abortion are likely to have already had more children than they expected. (Mahmood, 1993) More than one third of currently married Pakistani women do not want to have any more children. It is reported that 40 percent of currently married women have a need for family planning: 27 percent want to stop childbearing and 13 percent prefer to space their children. Since only 12 percent of married women are currently using contraception, 28 percent have an unmet need for family planning services (Pakistan Demographic and Health Survey 1990-91). The PDHS 1990/1991 has reported that in recent years the Total Fertility Rate (TFR) has declined from 6.3. This decline, however, is attributed to a rapid increase in age at marriage rather than a significant rise in contraceptive use. (Ahmed, 1992) Political Context Pakistani women are known for seeking clandestine abortion services which are mostly unsafe. The deaths, serious health complications, and long-term disabilities that result from unsafe abortion procedures place an enormous burden on Pakistans health care system, as well as on the women themselves, their families and their communities. Though it is apparent that increasing access to family planning and awareness to contraceptive methods can decrease the number of abortions, changes in government policy have been virtually non-existent. (Guttmacher.org/abortion 2011) The Family Planning Act of 1953 created the Family Planning Association of Pakistan, which is a private Non-Governmental Agency was the first attempt by the country to address contraceptive needs of women. This act was a part of an overall effort to improve womens health. Yet further progress was slow to follow. As stated in the Life and Necessary Ordinance of 1990, abortions are only allowed in cases where the womans life is in danger and in the cases of providing necessary treatment. What constitutes necessary treatment is never elaborated upon. However, what is clear is that no allowance is made for voluntary abortions or in situations of rape. (Shah, 1986)

The municipal hospitals offer limited abortion services, although abortion is legal in a few limited circumstances, abortion services are rarely available in government facilities. Some medical practitioners provide services for lifesaving abortions. Many more are unwilling to do so because of religious and personal beliefs or the fear of being labeled an abortionist. Information about contraception is similarly absent from many clinics. Many families believe that children are a gift of Allah and any interference in the process of child-bearing is a sin and calls for Allahs wrath. (Bruce J. 1995) Such beliefs were reinforced by some undesirable experiences, such as death of an Intra Uterine Contraceptive Device (IUCD) user and complaints of weakness and poor health amongst contraceptive users in the community. Unfortunately, since most families are dominantly patriarchal, non-invasive male contraceptive methods, such as condoms, are rarely considered, as they are deemed inconvenient. Analysis and Conclusion: In general, Pakistani people and the government hold traditional and religious beliefs in high esteem and consider family planning heretical to Islamic law. The lack of consistent government commitment to provision of family planning services and social and religious objections have led to major obstacles to reducing fertility (Zheng 1991). Unfortunately, there is misinformation when it comes to Islam and abortion. Pakistan is an Islamic state, where people, not only take pride in strictly adhering to the Islamic values but are ready to sacrifice their loved belongings for the glory and sanctity of Islam. Islam has accorded a highly venerated social position to women. Islam acknowledges the rights and privileges of the women in society. Likewise, Islam does not impose any restrictions that may hamper the social growth and development of the woman. The woman plays a vital role in building the society on healthier and stronger foundations. Yet in Pakistan, The women in Pakistan have been constantly complaining of having being isolated from the mainstream of society. (Mahood, 1977) There needs to be more education and awareness about womens rights overall and local tribal governments must recognize that women have a voice. Any kind of change to government policy that prioritizes the elimination of abuse and gender bias must come from a grassroots movement at the local Balochi government level. Presently, small-scaled initiatives need to be started to educate women, raise awareness about womens rights, and direct requests to the government that women are conscious of their plight. Unless the local government takes the leadership role in becoming the stimulus for change, womens health will be neglected. Presently, women in Pakistan are attaining education and becoming members of the workforce in large cities. The unfortunate fact also is that till now in rural areas women have not been educated or involved in having their voice heard. They simply lack awareness of how their quality of life can be improved. In Pakistan, the number one reason for maternal mortality is postpartum hemorrhage. Other complications are sepsis, perforation of uterus, visceral injuries, fistulas, and infertility are just a few of the consequences of lack of womens health. In order to improve this situation, we need to improve transportation to hospitals, implement consistent practice of active management of third stage labor, improve the availability of blood products at hospitals. (mdg.org, 2012, Ali, 2005) To reduce death from sepsis, we need to teach midwives about clean delivery and have clean

delivery kits available, institute better infection prevention procedures in hospitals. The health infrastructure in rural Pakistan is understaffed and lacks adequately trained personnel to safely deliver babies or manage antepartum, peripartum or postpartum complications. Often, if a case complicates, there is no time to reach a hospital, nor is this an option for some poor women. Local midwives that do not have the training to handle such situations treat the majority of abortions and complications. This lack of priority on womens health reflects a misbalance in emphasis of preventing womens illnesses and death. Ultimately women in better health will be better equipped to care for their families and contribute to society. Presently, there are many projects in place that encourage women to seek entrepreneurship and vocational training. (Ali, 2005) Pakistan has many more issues such as political climate and providing essentials like clean water and electric to the people of Pakistan than mobilizing resources to help womens health. This situation can be rectified only by the efforts of the Health Authorities, the Medical Professionals and United States governments support in concert to decrease morbidity and mortality. Financial support would allow for encouragement of collaboration between community based organizations all over the country to renovate and establish clinics, distribute medical supplies, educate the public through various media, and train traditional birth attendants and midwives. My request is the local government of Balochistan to help improvise this type of health care system in which women can have increased access to obstetrical and gynecological services.

References: Ahmed T. (1992) Patterns of demand for children in Pakistan. Pakistan Population Review 3(1): 41-66. Agarwala S.N. (1967) Family planning program in India. In Agarwala S. N. (ed.) Population pp. 85-100. National Book Trust, New Delhi. Ali, M; Hotta, M; Kuroiwa C; Ushijima, H. (2005). Emergency Obstetric Care in Pakistan: Potential for reduced maternal mortality through improved basic EmOC Facilities, services, and access. In International Journal of Gynecology and Obstetrics Vol. 91, Issue 1 (pp. 105-112). Maryland, USA: Elsevier Inc. Baburajan P. K. and Verma R. K. (1993) Psycho-social determinants of contraceptive initiation in India. Journal of Family Welfare 39(3): 5-12. http://www.thebalochhal.com/2010/01/balochistans-hospitals-have-capacity-of-4278-beds-dghealth/ Accessed February 07, 2012 Bongaarts J. and Bruce J. (1995) The Causes of Unmet Need for Contraception and the Social Content of Services. Studies in Family Planning 26(2): 57-75. Bryant J. H., Marsh D. R., Khan K. S., DSouza R., Husein K., Aslam A., Qureshi A. F., DeWit V. and Harnar R. M. (1993) A Developing Countrys University Oriented toward Strengthening Health Systems: Challenges and Results. American Journal of Public Health 83(11): 1537-43. Caldwell J. C., Immerwahr G. and Ruzicka L. T. (1982) Illustrative analysis: family structure and fertilty. World Fertility Survey Scientific Report No. 39. International Statistical Institute, Voorburg. Cleland J. and Wilson C. (1987) Demand theories of the fertility transition: An iconoclastic view.Population Studies 41(1): 5-30. Farooqui M. N. (1994) Interpersonal communication in family planning in Pakistan. Pakistan Development Review 33 (4 pt 2): 677-84. Kabir M.and Elahi K. M. (1992) Family welfare education and motivation programmes in rural Bangladesh. In: Bose A. and Premi M. K. (ed.) Population transition in South Asia pp. 179-99. B. R Publishing Corporation, New Delhi. Kulu I. (1990) Husbands as decision-makers in relation to family size: East -West regional differentials in Turkey. Nufusbilim Dergisi/ Turkish Journal of Population Studies 12: 41-64. Mahmood N. and Ringheim K. (1993) Five factors affecting family planning use in Pakistan: an analysis of husbands and wives. Presented at the International Population Conference, Montreal, Canada August 24-September 1, 1993. Mahmood T. (1977) Family planning: the Muslim viewpoint. Vikas Publishing House, New Delhi.

Mita R. and Simmons R. (1995) Diffusion of the Culture of Contraception: Program Effects on Young Women in Rural Bangladesh. Studies in Family Planning 26(1): 1-13. National Institute of Population Studies; Macro International Inc. (2007). Pakistan Demographic and Health Survey 2006-07. Islamabad, Pakistan: National Institute of Population Studies; Macro International Inc.

Pariani S., Heer D. M. and Van-Arsdol M. D. Jr.(1991) Does choice make a difference to contraceptive use? Evidence from East Java. Studies in Family Planning 22 (6): 384-90. Raju S. (1987) Husband-wife communication and contraceptive behavior. Journal of Family Welfare 33(4): 44-48. Ravindran T. K. (1993) Users perspectives on fertility regulation methods. Economic and Political Weekly 28(46-47): 2508-12. Reddy M. M.(1983) Communication factors and their influence on family planning behavior among non-adopters. Journal of Family Welfare 29(3): 12-20. Sarker P. C. (1993) Decline of traditional family system and reproductive behaviour in rural Bangladesh. Indian Journal of Social Science 6(1): 65-75. Sedgh G; Hussain R; Bankole A; Singh S. (2007). Women with an Unmet Need for Contraception in Developing Countries and Their Reasons for Not Using a Method. Occasional Report No. 37. Shah N. M. (1986) Contraceptive knowledge, attitudes and practice. In: Shah N. M. (ed.) Pakistani women: a socioeconomic and demographic profile, pp. 302-32. Pakistan Institute of Development Economics, Islamabad. Situation Analysis of "Unsafe Abortion and its complications", A FIGO initiative. Report of a National Workshop at Karachi; 2008 May. United Nations. (1993) Womens Status and Fertility in Pakistan: Recent Evidence. Department for Economic and Social Information and Policy Analysis ST/ESA/SER.R/135, New York. United Nations. (1995) Population And Vital Statistics Report. Statistical Papers Series A Vol.XLVII, No. 4, New York. Zheng J.(1991) Survey Report: Pakistan. Population Today 19(10): 5. http://www.mdg5watch.org/index.php accessed February 8, 2012 http://www.guttmacher.org/media/nr/2009/11/04/index.html accessed February 8 , 2012

http://www.medicalnewstoday.com/releases/30301.php accessed February 8 , 2012 http://www.guttmacher.org/pubs/IB_Abortion-in-Pakistan.pdf accessed February 8, 2012