In BriefAbortion in Pakistan

The deaths, serious health complicationsand long-term disabilities that resultfrom unsafe abortion procedures place anenormous burden on Pakistans healthcare system, as well as on the womenthemselves, their families and theircommunities. A national survey of public-sector facilities estimated that about200,000 women were hospitalized forabortion complications in 2002.1 Manyother women suffered complications butnever reached hospitals.

Current law permits abortion only to savethe womans life or, early in pregnancy,to provide necessary treatment (seebox, page 2). Because almost allabortions take place illegally and insecret, information about abortion inPakistan comes largely from studies ofwomen hospitalized for abortion compli-cations. While the evidence is limited, itis clear that postabortion complicationsaccount for a substantial proportion ofmaternal deaths in Pakistan.

How widespread is abortion inPakistan?A nationwide study estimated that890,000 induced abortions took place in2002.1,2 This amounts to 29 abortionsper 1,000 women of reproductive age(Table 1, page 2). Of every 100 pregnan-cies, 14 ended in induced abortion.

Abortion rates appear to be substantiallyhigher in the two more rural of Pakistansfour provinces. In North West FrontierProvince (NWFP), an estimated 37 abor-tions took place per 1,000 women aged1549, and in Balochistan the rate was38 per 1,000.1 By comparison, rates werelower in the two more urban provinces25 in Punjab and 31 in Sindhwherecontraceptive use is somewhat higher.

Because it is almost impossible toobtain reliable data on induced abortionthrough direct interviews with women,these rate estimates derive from anestablished indirect method that useshealth facility data on women treated forpostabortion complications and expertsestimates of the likelihood of hospital-ization after abortion. Given the stigmaand illegality of abortion in Pakistan,women themselves are very reluctant to

admit to having had induced abortions.For example, at a Karachi teachinghospital in 19971998, only 7% of thewomen presenting with postabortioncomplications acknowledged that theirabortions had been induced.3

Some small-scale community-basedstudies provide measures of the preva-lence of induced abortion and alsosupport the conclusion from the nationalstudy that the level of abortion ismoderately high in Pakistan. A study inan urban slum in Lahore in 19921993found that 16% of a random sample ofwomen reported having had at least oneinduced abortion.4 More recently, aqualitative 2006 study of a village inRawalpindi district found that 20% ofpregnancies resulted in abortions orattempted abortions.5

The latest Demographic and HealthSurvey (DHS) in Pakistan, conducted in20062007, found that 24% of birthswere unplanned.6 While the level ofinduced abortion may not be known withprecision, it is clear that the procedureis common in all regions, despite itsillegality, and that it is a response tothe high level of unintended pregnancy.

Who are the women havingabortions?If the women hospitalized for abortioncomplications are typical, most womenwho have induced abortions in Pakistanare married and already have morechildren than the average Pakistaniwoman wants (Figure 1, page 3).7 In onestudy, 70% of women were aged 2539;7

in another study, 78% were aged 2534.8

The average age of the women reported

2009 Series, No. 2

In 2002, Pakistani women experienced about 2.4 million

unintended pregnancies;* nearly 900,000 of these pregnan-

cies were terminated by induced abortion. Because abortion is

legal only in very limited circumstances, women who seek it

subject themselves to clandestine and often unsafe proce-

dures. Poor women, in particular, are forced by circumstances

to rely on untrained providers.

*Numbers are based on calculations using datapresented in reference 1.

in several studies was justunder 30.911 Moreover, almostall the women were married.11,12

This pattern is typical of manyAsian countries: Most abortionsoccur among currently married,older women and not amongunmarried adolescent women,as is more typical in regionssuch as Sub-Saharan Africa.

The number of living childrenthat women already have whenthey decide to abort is quitehigh, and since Pakistaniwomen want an average of 3.1children,6 the women who seekabortion are likely to havealready had more children thanthey wanted. Some studies ofpostabortion care patients have

found that their average parityis around four children.911

Other studies show that about50% or more of womenhospitalized for postabortioncomplications had five or moreliving children.7,8,12

With regard to other possiblecontributing factors, evidenceto date does not indicate thateither womens education ortheir contraceptive usebehavior influences whether ornot they resort to inducedabortion. In fact, some studiesshow that the educationalprofile of women who haveinduced abortions is similar tothat of the female populationin general.11,13

What are the consequencesof unsafe abortion?Unsafe abortion in Pakistancontributes significantly toavoidable illness and death.Studies document that whenwomen who have had unsafeabortions do reach healthfacilities, they commonly sufferfrom a range of postabortioncomplicationsincompleteabortion, hemorrhage orexcessive bleeding, trauma tothe reproductive tract oradjacent anatomical areas,sepsis (bacterial infection) anda combination of thesecomplications.3,811,1316

Excessive bleeding may havelife-threatening consequences,such as anemia or shock.Perforations and lacerationsmay occur to the vagina,cervix or uterus and mayinvolve injury to adjacentareas, such as the intestines,requiring surgery with fullanesthesia. Hysterectomy(removal of the uterus) may berequired, leaving the womanpermanently infertile. If nottreated in time, sepsis can leadto peritonitis (inflammation ofthe abdominal lining), sep-ticemia (blood poisoning),kidney failure and septic shock,all of which can belife-threatening.

In 2002, an estimated 197,000women were hospitalized forcomplications of unsafeabortion.1 This amounts to 6.4hospitalizations per 1,000women aged 1549. High asthis figure is, it likely repre-sents only a portion of theactual number of womenexperiencing complications.For instance, Pakistani expertsestimate that only around halfof poor women who needtreatment for severe complica-

tions of abortion reachhospital-based care.12 Moreaffluent women are consideredto be more likely to obtaincare for abortion complica-tionsabout four in five whoneed hospital-based care likelyreceive it. In addition, womenwho are poor and live in ruralareas are considered to beleast likely to obtain carewhen they havecomplications.1,2

A few small-scale facility-based studies have given us apartial picture of the trueextent of the tragedy of deathresulting from an unsafeabortion. They show that evenwhen women do reachhospitals, perhaps one in 10die. During a 21-month periodin 19971998, for example,10% of women admitted to alarge teaching hospital inKarachi for postabortion caredied of complications.3

Septicemia was the mostcommon cause of death.

Such deaths represent asubstantial proportion of allmaternal deaths occurring inhospitals. A 19992001university hospital study foundthat 11% of maternal deathsthat occurred in the hospitalduring this period were causedby complications resulting fromunsafe abortion.14 In an earlierhospital study (19921994),unsafe abortion caused 15% ofmaternal deaths.8

These studies likely reveal onlythe tip of the iceberg. Little isknown of the fate of thewomen who need treatmentbut do not receive it. Inaddition, other importantconsequences of unsafeabortion have not been

Abortion in Pakistan 2 Guttmacher Institute

The Legal Status of Abortion in PakistanIn 1990, the Pakistan government revised the colonial-era Penal Code of1860 with respect to abortion. The revisions sought to conform better toIslamic teachings regarding offenses against the human body. Under the1990 revision, the conditions for legal abortion depend on the developmen-tal stage of the fetusthat is, whether the fetuss organs are formed or not.Islamic scholars have usually considered the fetuss organs to be formed bythe fourth month of gestation. Before formation of the organs, abortions arepermitted to save the womans life or in order to provide necessary treat-ment. After organs are formed, abortions are permitted only to save thewomans life.

Likewise, the penalties for illegal abortion depend on the fetuss develop-mental stage at the time of the abortion. Before organs are formed, theoffense is penalized under civil law (tazir), by imprisonment for 310 years.After organs are formed, traditional Islamic penalties, in the form of compen-sation (diyat), are imposed. Depending on the outcome of the abortion,imprisonment may be imposed as well.

Source: United Nations Population Division, Abortion Policies: A Global Review,New York: United Nations, 2002.

Estimates of the annual abortion rate and number of induced abortions,by province and nationally, 2002

Level of Abortion

Province Rate* No.

Punjab 25.4 457,000Sindh 30.9 218,000NWFP 37.3 160,000Balochistan 37.5 55,000

All 29.0 890,000

Table 1

*Abortions per 1,000 women aged 1549. Sources: References 1 and 2.

studied in Pakistaninparticular, long-term disabili-ties, infertility and theeconomic costs to individuals,families, the health caresystem and society.

Who performs abortions,and how are they done?Both formally trained healthpersonnel and traditionalpractitioners perform abortionsin Pakistan, frequently underunsafe conditions. Who performs

the abortion and how safe it isoften depend on where awoman lives and how muchshe can afford to pay for theprocedure.

Poor rural women are muchmore likely to obtain abortionsfrom untrained providers thanare nonpoor urban women.As part of the 2002 nationalstudy, more than 100 knowl-edgeable health professionals,drawn from all four provinces,

considered how womenseconomic status and residenceinfluence access to formallytrained abortion providers.12

They estimated that, onaverage, only 7% of poor ruralwomen obtained their abor-tions from doctors, while 42%went to dais (traditional birthattendants). By comparison,an estimated 49% of nonpoorurban women had doctorsperform their abortions, whileonly 9% went to dais. Amongpoor women who lived inurban areas, an estimated 34%went to dais.

According to the 2002 surveyof health professionals, theprice of an abortion variesdepending on the type ofprovider and the womansability to pay.12 For example,poor rural women pay anestimated US$21 for anabortion provided by a nurse-midwife, nonpoor rural womenand poor urban women payUS$30, and nonpoor urbanwomen pay US$48. Poor ruraland poor urban women who goto dais or other lay practition-ers pay the equivalent ofUS$817. These prices high-light the inequity in Pakistaniwomens access to safeabortion: More affluent womencan afford expensive, saferabortion procedures, while poorwomen must make do withuntrained personnel whose careis less expensive but oftenriskier and more harmful.

Going to a trained health careprovider for an abortion is noguarantee of safety, however.Many women who experiencecomplications have hadabortions performed by doctorsor nurses. At a large teachinghospital in Karachi in 1997

1998, 30% of women receivingcare for abortion complicationstold researchers that a doctorhad performed their abortions,and 36% said a nurse or ladyhealth visitor had done theprocedure.3 Dais had performedthe abortion for 32% of thewomen. Only 2% had had aself-induced abortion. In urbansquatter settlements inKarachi, women listed privatehospitals, clinics and daishomes as the most commonplaces to obtain abortions.16

Abortions can be obtained inclandestine clinics, at least inlarge urban areas and providedone can afford the costbutagain, they are not alwayssafe.13 Of 32 clinics studied in1997 in three provincialcapitals, 10 clinics were runby female doctors, 13 by ladyhealth visitors, six by othertypes of nurses and three byparamedics. Although mostclinics employed trainedpersonnel, only seven wereproperly equipped to carry outabortions safely. Providerstypically performed dilationand curettage procedures.They almost never used manualvacuum aspiration, a lessinvasive and safer procedure.

Abortions seem to take placeat a fairly early gestationalage. Among women receivingpostabortion care at a largeteaching hospital in Karachi,43% had had their abortion inthe first eight weeks ofgestation and another 39%had had the procedurebetween the ninth and 14thweeks.3 Nonetheless, 18% ofwomen had waited until 15weeks or later, when theprobability of severe complica-

Abortion in Pakistan 3 Guttmacher Institute

Half of Pakistani women having abortions are in their 30s, nearly allare married and most have at least three children.

Women Who Have Abortions

1519

2029

3039

40+

None

12

34

5+

Single

Married

Number of children

Marital status

Age

14%4%

32%

50%

97%

49%

3%

16%

32%

3%

Source: Reference 7.

Figure 1

tions is elevated. The study ofclandestine abortion clinicsfound that abortions at suchclinics took place at an evenearlier gestational age, onaverage.13

In general, what we knowabout how abortions take placein Pakistan is limited toinformation obtained throughfacility-based investigations.Since women who either haveno negative health conse-quences or who endure illnesswithout treatment are notreached through facility-basedstudies and are very unlikely tohave reported their abortionexperiences in the few existingcommunity-based studies, thepatterns of abortion procure-ment described here may wellpresent an incomplete picture.

Why do women haveabortions?Given the health risks, theillegality and the stigma, whydo so many women haveabortions? Unintended preg-nancy is the primary reasonwomen seek abortions, andstudies have probed theunderlying reasons for theunwantedness of thosepregnancies. Poverty andhaving had all the childrenthey want are the two mostcommon factors cited bywomen as their reason fordeciding to terminate apregnancy.7,10,13 In a 2002study in three of Pakistansfour provinces, 54% of womenwho had had abortions saidthat they could not afford tohave another child, 55% saidthat they had had enoughchildren, and 25% said that itwas too soon to have hadanother child (women could

give more than one reason).7

Similarly, in low-income areasof Karachi, too many chil-dren, poverty and unem-ployed spouse were the mostcommon reasons why womensought abortions.15,16

In 1997, clients at clandestineabortion clinics in threeprovincial capitals reported asomewhat different mix ofreasons for abortion.13 While64% said their primary reasonwas too many children,which is consistent with bothof the major reasons men-tioned above, other reasonswere also cited. For example,20% said their contraceptivemethod had failed; nearly allof these women96%hadbeen using traditional meth-ods. Some 5% cited medicalreasons as the primaryrationale for their abortions.Premarital affairs werementioned by 9% of women,and extra-marital affairs by1%, indicating that in Pakistanrelatively few pregnanciesoccur outside marriage.

These findings suggest thatmany married women and theirhusbands have difficultiesobtaining contraception orusing it effectively, and thatabortion is often used as aback-up when unintendedpregnancies occur. Womenspredominantly economicreasons for abortion speak tothe burden that addinganother child to the householdcan place on some Pakistanifamilies. This same rationalecould motivate wider contra-ceptive use if effective familyplanning methods were moreavailable and their use weremore acceptable.

How does contraceptiveuse relate to unintendedpregnancy and abortion?While contraceptive useincreased gradually in Pakistanuntil 2003, it has changedrelatively little since then(Figure 2).6 Nationally, onlyabout 30% of married womenof reproductive age currentlyuse a contraceptive method,according to the 20062007DHS survey. Moreover, morethan one-quarter of contracep-tive users rely on traditional,low-efficacy methods such aswithdrawal or periodicabstinence, leaving themselveslargely unprotected againstunintended pregnancy. Thesurvey asked women who werenot currently using a methodabout their intention to useone in the future.Encouragingly, half said thatthey intended to use contra-ception in the future; it is notknown why these women werenot using a method at thetime. Most of the rest saidthey did not intend to use inthe future, and a small

proportion were unsure whatthey would do. Women whodid not intend to use contra-ception in the future wereasked why. Among the keyreasons were fatalism (forexample, Its up to God),cited by 28%; a perceptionthat they are not at risk ofpregnancy (25%); and opposi-tion by the respondent, herhusband or others (23%).About 15% of the group gavereasons related to side effectsor lack of knowledge aboutcontraception.

Compared with the cross-section of Pakistani women inthe DHS survey who were notusing contraception and didnot intend to do so in thefuture, a higher proportion ofclients interviewed at clandes-tine abortion clinics in 2002expressed concerns about thesafety of contraceptivemethods (46%).13 To a verygreat extent, however, amongwomen having abortions, mostof those who report that they

Abortion in Pakistan 4 Guttmacher Institute

Contraceptive use, after rising steadily, has plateaued in recent years.Trend in Contraceptive Use

%of

marrie

dwom

enaged

1549usingcontaception

20030

10

20

30

40

50

60

70

80

90

100

200620072000200119961997199419951990199119841985

12

32 30

1824

9

28

Source: Reference 6

Figure 2

experienced contraceptivefailure were using methodswith relatively low levels ofeffectiveness (condoms,withdrawal and rhythm).

While Pakistans fertility rate ishigh compared with moredeveloped countries, it is lowerthan would be predicted by thecountrys low level of contra-ceptive use: On average,women have 4.1 live births,and, in metropolitan areas, therate is just 3.0 live births. It isdifficult to explain suchfertility rates solely in terms ofcontraceptive use. Inducedabortion is likely to be animportant contributing factor.The fact that women in thetwo less developed provincesBalochistan and North WestFrontier Provincehave lowercontraceptive use rates andhigher abortion rates thanwomen in the more developedprovinces supports thisinterpretation.1

There appears to be a greatneed to increase and improvecontraceptive use in Pakistan.One-quarter of currentlymarried womenan estimated6.6 million women in 2007

have an unmet need forcontraception (Figure 3).6 Inother words, they either donot want any more children ordo not want a child at thepresent time, but they are notusing contraception. Moreover,there continues to be asignificant gap in womensability to have the family sizethey wantwomen report thatthey want three children, eventhough on average they arehaving four.

ConclusionsThe combination of a relativelyhigh national level of fertilitywith a relatively low level ofcontraceptive use and amoderately high rate ofabortion suggests that manyPakistani women are usingabortion as part of theirstrategy to avoid unwanted ormistimed births, notwithstand-ing the illegality of theprocedure and the considerablehealth risks it entails, asevidenced by the large numberhospitalized for treatment ofcomplications each year. Theneed to seek recourse toabortion is likely to beespecially prevalent amongwomen who fear that contra-

ceptives will damage theirhealth, who believe that theirhusbands object to familyplanning or who feel thatreligious and social norms donot endorse contraceptive use.In addition, many women mayhave difficulty obtaining themodern methods they need.

Under current circumstances,many Pakistani women arepaying with their healthandeven their livesto avoidbirths that they cannot affordor do not want. Helping themavert unintended pregnancyand supporting them inachieving their fertility goalswould significantly reducematernal morbidity andmortality and the associatedcosts to families, communitiesand society as a whole.

REFERENCES1. Sathar ZA, Singh S and FikreeFF, Estimating the incidence ofabortion in Pakistan, Studies inFamily Planning, 2007,38(1):1122.

2. Population Council, UnwantedPregnancy and Post-AbortionComplications in Pakistan: FindingsFrom a National Study, Islamabad,Pakistan: Population Council, 2004.

3. Bhutta S, Aziz S and Korejo R,Surgical complications followingunsafe abortion, Journal ofPakistan Medical Association, 2003,53(7):286289.

4. Maternity and Child WelfareAssociation of Pakistan (MCWAP),Reproductive Morbidity in an UrbanCommunity of Lahore, Karachi,Pakistan: MCWAP, no date.

5. Arif S and Kamran I, Exploringthe Choices of Contraception andAbortion among Married Couples inTret, Rural Punjab, Pakistan,Islamabad, Pakistan: PopulationCouncil, 2007.

6. National Institute of PopulationStudies (NIPS) and MacroInternational, PakistanDemographic and Health Survey200607, Islamabad, Pakistan:NIPS, 2008.

7. Casterline J and Arif S, Dealingwith unwanted pregnancies:insights from interviews withwomen, Research Report,Islamabad, Pakistan: PopulationCouncil, 2003, No. 19.

8. Tayyab S and Samad N, Illegallyinduced abortions: a study of 37cases, Journal of the College ofPhysicians and Surgeons Pakistan,1996, 6(2):104106.

9. Jamil S and Fikree FF,Incomplete Abortion from TertiaryHospitals of Karachi, Pakistan,Karachi, Pakistan: Department ofCommunity Health Sciences, AgaKhan University, no date.

10. Korejo R, Noorani K and BhuttaS, Sociocultural determinants ofinduced abortion, Journal of theCollege of Physicians and SurgeonsPakistan, 2003, 13(5):260262.

11. Siddique S and Hafeez M,Demographic and clinical profile ofpatients with complicated unsafeabortion, Journal of the College of

Abortion in Pakistan 5 Guttmacher Institute

Modern methods

Traditional methods

Unmet need

Not in need

About 30% of married women aged 1549 use contraception, whileanother 25% experience unmet need.

Contraceptive Use and Unmet Need

22%

8%

25%

45%

Figure 3

Source: Reference 6.

Physicians and Surgeons Pakistan,2007, 17(4):203206.

12. Rashida G et al., Abortion andPost-Abortion Complications inPakistan: Report from Health CareProfessionals and Health Facilities,Islamabad, Pakistan: PopulationCouncil, 2003.

13. Rehan N, Inayatullah A andChaudhary I, Characteristics ofPakistani women seeking abortionand a profile of abortion clinics,Journal of Womens Health & Gender-Based Medicine, 2001,10(8):805810.

14. Mahmud G and Mushtaq Z, TheIncidence and Outcome of InducedAbortions at One of the Hospitals ofIslamabad, Islamabad, Pakistan:Population Association of Pakistan,2001.

15. Saleem S and Fikree FF, Inducedabortions in low socio-economicsettlements of Karachi, Pakistan:rates and womens perspectives,Journal of the Pakistan MedicalAssociation, 2001, 51(8):275279.

16. Jamil S and Fikree FF,Determinants of Unsafe Abortion inThree Squatter Settlements ofKarachi, Pakistan, Karachi, Pakistan:Department of Community HealthSciences, Aga Khan University, nodate.

CREDITSThis In Brief was written byMichael Vlassoff, Susheela Singhand Gustavo Suarez, all of theGuttmacher Institute, and SadiquaN. Jafarey of the NationalCommittee for Maternal andNeonatal Health (NCMNH),Pakistan. It was edited by WardRinehart, independent consultant,and Haley Ball, GuttmacherInstitute.

The authors thank Zeba Satharand Ali Mohammad Mir, both ofthe Population Council, Pakistan,and Imtiaz Kamal, Azra Ahsan,Nighat S. Khan and MariumWaqas, all of NCMNH, for theircomments on drafts of the report.They also thank the followingGuttmacher colleagues: PatriciaDonovan, for her input on drafts,and Alison Gemmill and Liz Carlin,for research assistance.

The 2002 national study on whichmany of the reports findings arebased was supported by a grantfrom the David and Lucile PackardFoundation to the PopulationCouncil, Pakistan.

Suggested citation: Vlassoff M etal., Abortion in Pakistan, In Brief,New York: Guttmacher Institute,2009, No. 2

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