Pretend it's never happened. As we often do for everything unpleasant, push it under the ever-accommodating Pakistani carpet. We're talking unsafe abortion — stark, clandestine, hush-hush, pain-filled, back-street, unhygienic, and dangerous, continuing unceasingly, with unremitting loss of life.

Every year, 890,000 women suffer spontaneous or induced abortions; contributing to Pakistan's shockingly high statistics for maternal illness and death. 197,000 women end up suffering serious health complications as a consequence of induced abortions. Why? The reasons are complex, and after all these years, still lacking satisfactory solution. They spell a significant and very grave danger to women's lives, particularly in developing countries.

In Pakistan, as opposed to general belief, unsafe abortion is not a risk undertaken by women who have conceived due to extra-marital or pre-marital sex, though that too happens — rather, the majority of women who seek abortion are mothers with five, six or seven children, who cannot afford any more children, and/or are exhausted with child-bearing and child-rearing.

The reasons for too many children, and possibly consequent induced abortion, vary. Despite considerable expansion, availability and accessibility of family planning facilities is still limited, as is the information about the benefits of family planning; the latter does not fully satisfy the anxiety of women or couples.

They often stop using contraceptives for fear of side effects (generally minor) which may be considered serious. Couples are often either not informed or are inadequately informed about both the benefits and the side effects of family planning, with the result that when side effects occur, women stop using contraceptives.

Comprehensive information to women and couples about the qualities and efficacy of different contraceptives is essential. Sometimes, contraceptive failure occurs; at other times, it's difficult to access the much-needed reproductive health care. Or the husband, or couple, may be reluctant to practise family planning; son preference factor also plays a part.

Cost is another factor purchasing contraceptives privately is expensive, and distribution through government outlets is inadequate. The end result is a high proportion of unwanted pregnancies, and the risk of unsafe abortion.

The commonest reason for the high incidence of induced abortion is non-use of contraception people who are unaware of the dangers of unsafe abortion end up using this as a means of family planning.

Consultant gynaecologist and obstetrician Dr Azra Ahsan raised a significant point “Although the number of children born to each woman is declining nationally, the contraceptive prevalence rate has remained static, at about 30 per cent. Logically, the number of children per woman should reduce if contraception was easily accessible, widely available and regularly practised, but when there appears to be little or no increase in contraceptive use, how and why is the fertility rate going down?”

She considers the reason to be at least partly linked to the prevalent use of abortion as a method of family planning, leading to fewer births per woman. This also means that women are paying with their lives, and suffering untold pain, for the inadequacy of family planning facilities.

The answer to reducing this tragic human toll lies in providing extensive, comprehensive facilities, with effective counselling, so that people can make more informed choices and decisions about the method of contraception that they wish to use.

Undoubtedly, effective family planning measures are essential; nevertheless, mishaps and contraceptive failures do occur. Given that countless women are faced with the dilemma of unwanted pregnancies, there is a distinct need to address this situation and provide safe abortion facilities for women who would otherwise be risking their lives with unsafe abortion.

 
This continues even though abortion is legally permissible in specific circumstances in Pakistan. But despite the legal sanction, it is distressing that risky, unhygienic operations continue in such high numbers. A small number of women who can afford quality medical care have access to safe abortion facilities; others have no alternative but to fend for themselves.

In the absence of skilled care, desperation drives women to either seek the intervention of traditional untrained dais, or carry out self-treatment with herbal mixtures, or 'instruments' such as twigs and knitting needles. Obviously this leads to complications, with high rates of infection. Damage to internal organs is frequent — bowels, urinary bladder, uterus, important blood vessels; all can get affected, with sepsis, internal injuries, renal failure, hepatitis and hepatic failure, peritonitis, pelvic infection, or uterine perforation.

Of these, sepsis is a major killer, followed by internal injuries. The majority of women who undergo abortion experience excessive bleeding, while many undergo unwarranted pain. Relatively few women receive post-abortion counselling.

 
Women not only endure physical pain, they are forced to live with society's judgemental and stigmatising attitudes. Their emotional, psychological, and physical suffering is borne by them alone, and partly by their families. They face chronic health problems, depression, and even premature death.

The use of unsafe abortion as a means of contraception would decline if improved family planning facilities and quality reproductive health care were made easily accessible and available. Post-abortion counselling, greater male involvement, and programmes to raise awareness of couples and women would be helpful. Indirect measures, such as increasing female literacy, and the rising age at marriage, are already resulting in fewer children.

So great is the plight of women who suffer due to unsafe abortion that a few professional organisations have come together to urge for the introduction of improved legislation and implementation of laws pertaining to women's reproductive health and to abortion. Most of all, it is essential to stress that a woman must have the right to obtain an abortion by her own choice within the first 120 days of pregnancy.

This right is particularly essential for women who have conceived as a consequence of rape or incest; in the case of seriously disabled girls, or if there is danger to the woman's life, or serious threat to her health. It is also essential in the case of exposure to disease or other hazards which may result in abnormality of the child.

The measures to save these precious lives are not even difficult to implement; most are cost effective, such as raising public awareness and improving the outreach of family planning services — then why this undue delay?