SAMAN WAS 21when she found out she was two months pregnant. She told her sister, her mother and her partner at the time. Her mother swiftly made arrangements: the next day, after dusk, she drove Saman to an informal abortion clinic on the outskirts of Islamabad and paid Rs50,000 for the procedure. “I remember lying on the operating table, yelling,” Saman told me over the phone. “Two nurses held me back as they administered anaesthesia.”

“Pakistan has an annual abortion rate of 50 per 1,000 women, the highest in South Asia and one of the highest in world.”

The procedure was short: not more than 45 minutes, typical for a dilation and curettage. Its associated risks are high: infection, excessive bleeding and subsequent cramps. The World Health Organisation (WHO) recommends it as a last resort, when no other methods are available. Seven years later, the trauma is still fresh in Saman’s head. “I try not to think about it too much,” she said. “I remember needles, being in pain, blood pooling near my legs, cramps lasting forever. I couldn’t open my eyes properly for weeks.” She received no post-op care and never spoke of the abortion ever again. It was almost as if it never happened.  

For the same procedure, Fatima paid nearly double at a private hospital in Lahore. “I was very lucky to be able to afford the abortion without having it impact by life in a hugely negative way. I went to a very well-respected gynaecologist and hospital—and though I was scared, I didn’t feel unsafe or as if they were incapable.” Even so, before the procedure, a nurse shamed her for rejecting ‘God’s blessing.’

Pakistan has an annual abortion rate of 50 per 1,000 women, according to a 2012 survey, the highest in South Asia and one of the highest in world. (A previous study estimated a rate of 27 per 1000 women in 2002.) Although Pakistani women are clearly seeking abortions, medical practitioners often refuse to perform them or do so only in secret—in general, both seekers and providers of abortions tend to believe the procedure is against religion or Pakistani law, or both. When I asked Saman, for instance, why she didn’t go to a proper hospital when faced with an unwanted pregnancy, she said she didn’t know a legal abortion was even a possibility. As it turns out, it can be.  

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IN PAKISTAN, UNTILjust over two decades ago, induced abortion was permissible only for the purpose of saving a woman’s life. The Pakistan Penal Code (PPC) largely draws from the colonial Indian Penal Code of 1860. But in 1997, an additional clause was added to Chapter XVI, Section 338 of the PPC: induced abortion is also permissible ‘before the limbs or organs of the baby have been formed’ for the purpose of ‘necessary treatment’. This stipulation, regarding limbs and organs is based on Islamic law, which states that induced abortion is permitted until the ‘quickening’ of the foetus—up to 20 weeks gestation, according to Pakistani medical practice. Induced abortions that fall outside these conditions may be punished with prison sentences ranging from three to ten years but, according to lawyer Sarah Malkani, there have been no cases of incarceration for abortion-related offences.   

“Necessary treatment” is not defined in the PPC, however, and the law does not specify situations when a woman would “need” an abortion, leaving it up to service providers and medical professionals to interpret the clause as they please. “I think people who want to encourage abortions would encourage service providers to interpret it broadly, to mean not just the physical health of a woman, but also her emotional and mental health,” said Malkani, adding that, “depending on where a woman falls within the legal exception, doctors should be a providing abortions, and all wards in government hospitals should have abortion facilities.”  

At his clinic in Karachi, Dr Shershah Syed routinely administers abortions free of charge, and regardless of marital status. He often receives cases of rape, marital abuse, and severe mental distress. “Practically speaking, abortion laws in our country are very liberal—they’re allowing doctors like myself to perform an essential service,” he says. “But the problem is our gynaecologists and obstetricians: they allow religious beliefs and bakwas to cloud their judgement when they say abortions are kufr, and they don’t acknowledge their patients’ plight.”

According to public health physician Dr Xaher Gul, a gynaecologist who refuses to administer an abortion in Pakistan is violating both the Hippocratic Oath and Standard 26 of the national abortion guidelines which states that healthcare providers have a right to conscientious refusal, but cannot impede or deny access or information about lawful abortion services to patients, delaying care and placing their health and life at risk. 

“Pakistan is a unique country,” he added. “Our laws around abortion are liberal and yet every six hours a woman dies because of abortion-related complications. Doctors are pushing women towards threat.” According to him, patriarchy and paternalism within the medical fraternity impede access and endanger lives. “A woman seeking an abortion is automatically assumed to be of bad character.”

Outside Dr Ruth Pfau Civil Hospital, one of Karachi’s largest public health facilities, Dr Gul once saw a woman murdered by a member of her family. “She was begging the gynaecologist for an abortion and the doctor swore at her, told her to go die at home. And then she got shot.”

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FARHAT SULTANA SUPERVISES127 Lady Health Workers in Karachi’s Baldia Town and has referred several women seeking abortions in her neighbourhood to local government hospitals. Invariably, her referrals are sent back home, where they attempt to self-induce by consuming large amounts of commonly available drugs. “It wrecks their bodies,” she says. She sees a hundred such cases every two months—women who have overdosed on over-the counter medication to induce abortions and end up suffering from complications, including incomplete abortions, excessive bleeding and sepsis, gangrene and internal organ injuries. 

According to gynaecologist Dr Saadia Ahsan Pal, many doctors who refuse to perform abortions then deal with the same patients after the women attempt to induce one at home. “One of my colleagues refused to administer an abortion for a patient,” she recalled. “The patient later asked my colleague if she would be willing to deal with her post-abortion complications, in the event that she induced an abortion at home.”

In addition to high rates of abortion, Pakistan also has one of the highest maternal mortality rates in South Asia. Nearly one in five women are likely to develop complications during childbirth, and roughly six per cent of all maternal deaths in Pakistan—according to statistics from 2007—stemmed from unsafe abortions. It is worth noting these numbers are most likely grossly underreported; data is only collected from women who approach health facilities with post-abortion complications. 

“I lied about being pregnant with a rapist’s child because she wouldn’t have been willing to perform the abortion if I told her it was consensual sex that bore this.”

In March 2018, the Ministry of National Health Services published a 32-page pamphlet listing guidelines for safe abortion practices and post-abortion care. According to the pamphlet, all women and girls have the right to high-quality safe, comprehensive uterine evacuation care and healthcare providers must provide high-quality care while protecting the human rights of their clients, including right to privacy and confidentiality, information, dignity and autonomy.

For the most part, however, these guidelines exist only on paper. “I was two and a half months pregnant and no one was willing to perform an abortion,” 20-year-old Maha told me. “Finally, a nurse at the hospital where I got my ultrasound suggested a doctor at another hospital.” When Maha approached her, the doctor kept asking how she’d gotten pregnant. “I lied about being pregnant with a rapist’s child because she wouldn’t have been willing to perform the abortion if I told her it was consensual sex that bore this.”

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GYNAECOLOGIST DR AZRAAhsan thinks the reluctance to perform abortions stems partly from ignorance—lots of doctors don’t know abortion is conditionally legal in the country. “No law that governs abortions is ever taught in medical schools, and doctors aren’t sensitised to it at all.”

“But the fundamental question,” Dr Syed asks, “is what are we teaching our doctors?” Abortion is a procedure barely taught or talked about in public medical colleges across Pakistan, and only briefly mentioned during medical forensics classes as a criminal act. “If we don’t change our curricula, medical schools in Pakistan will continue to produce glorified quacks, and women will keep dying.”

Zahra recently graduated from a five-year MBBS programme at a public medical college in Karachi, and is about to begin her medical internship on the gynaecology track. In her last year of medical school, she and her peers were shown how to assemble and disassemble a manual vacuum aspirator. This is a plastic syringe with a cannula that sucks pregnancy tissue out of the uterus, a procedure commonly used to perform first trimester abortions and considered much safer than the invasive dilation and curettage. “We had never seen the strange looking syringe before, and they told us manual vacuum aspirators aren’t available at local government hospitals, so we pretty much forgot about them,” she said.  

Zahra says she was taught nothing about the legal status of abortions in the country. In fact, she didn’t know about Article 338 of the PPC—and the ‘necessary treatment’ provision—until December last year, months after graduation, when she heard comedian Shehzad Ghias in conversation with public health specialist Dr Muhammad Moiz on a local podcast. In it, Dr Moiz reels of a distressing list of methods used by desperate women to induce abortions. A perturbed Ghias tries to stop him. “We don’t want to give people ideas,” he says, but Dr Moiz persists: “Women need to know these methods are harmful.”

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THE THIRD TIME34-year-old Aisha needed an abortion, she went to a local pharmacy in Karachi, instead of one of the city’s few clinics where abortions are administered under qualified medical supervision. Her last experience at a clinic had been particularly harrowing. “The doctor shamed me for destroying my uterus and my body, and said I needed to be more careful,” she said. “It was humiliating; I was too ashamed to go back again.”

At the pharmacy, Aisha asked for ST Mom, one of the local brand names for misoprostol, an anti-ulcer medicine that can induce an abortion for a pregnancy up to ten weeks along. In American clinics, misoprostol is prescribed along with mifepristone—a more effective and less invasive combination with a success rate of nearly 98 per cent if used within the first ten weeks of pregnancy. The combination is considered the safest way to terminate a pregnancy; in fact, in 2005, the WHO decided there was sufficient scientific evidence to strike the caveat stipulating the medications only be taken under close medical supervision. But because mifepristone is specifically a registered abortion drug, it is not available in Pakistan, or in other countries with restrictive abortion laws—despite being on the WHO’s essential medicines list.

“In Pakistan, where only 30 per cent of fertile-age women use modern contraceptives, abortion is often a primary family planning measure.”

Used alone—without mifepristone—misoprostol has a significantly lower later of inducing an abortion in the first trimester: between 65 and 75 per cent. “I thought it had worked,” Aisha told me. Bleeding and uterine contractions usually start within thirty minutes of the first dose, but the bleeding doesn’t always imply the abortion has occurred. In Aisha’s case, it hadn’t.

Aisha’s cramps persisted over several days and, the following month, she bled so profusely she had to be hospitalised. At the hospital, out of fear of being sent back or being refused treatment for attempt an abortion at home, Aisha did not tell her doctors the truth. “I told them I had misused my birth control pills by accident,” she said.

Limited abortion access does not mean women don’t access abortions. Indeed, in Pakistan, where only 30 per cent of fertile-age women use modern contraceptives, according to a 2017 United Nations report, abortion is often used as a primary family planning measure. While the typical profile of a woman seeking an abortion in Pakistan is a middle-aged married woman, with three or more children, all women seek abortions, says Dr Moiz, and their needs must be centred. “At the end of the day, abortion is an essential service. This needs to be a core topic when you’re studying public health or community medicine and if you want to be a gynaecologist or obstetrician, you must be feminist and you must be pro-choice. Otherwise, what’s the point?” ￭

ZUHA SIDDIQUIis assistant editor at Soch Writing.
Visuals by MARIUM ALI.

*Some names have been changed to protect privacy.

Correction: A previous version of the Abortion law in Muslim-majority countries infographic did not include the seventh abortion right i.e. Abortion available upon request.