In January this year, a woman in her early twenties named Sonia Akhter was brought to Dhaka Medical College Hospital haemorrhaging from a botched abortion. She was four months pregnant when the process was undertaken. The doctors could not save her.
Her death was reported in a couple of local dailies in the smallest possible corner of the metro page. Yet it stood out by how rare it is that such an incident even appears in the news. All the newspapers collectively reported on only three incidents of abortion-related deaths in the whole of last year. The rate is pretty much consistent over the years, add or subtract one.
Yet the Guttmachher Institute, a U.S. based non-profit, reported that 384,000 unsafe abortions led to health complications in 2014. Guttmacher is pretty much the only organisation to have a complete, comprehensive survey of incidents of abortion in recent history. To arrive at this number the study parterned up with Bangladesh Association for Prevention of Septic Abortion and painstakingly collected data from NGO facilities at local levels. They presented their findings last week in Dhaka.
Sonia's case came into the highlight because she was brought into DMCH which hosts a fleet of stand-by reporters communicating with all news organisations. Clearly the odds of that happening are one in a lakh.
The gross levels of underreporting of casualties, combined with the general hush-hush aura of the issue, means that very little is known about abortion. Sonia's death happened around the same time that all large international media houses were thick with coverage about abortion rights, and I realised how little information about our own country's abortion laws exist within general knowledge. I asked everyone around me if they even knew whether abortion is legal in this country. Nobody did.
Turns out, it's not. Abortion is still outlawed by a law from the - drumroll please - 1860's. The Penal Code, more specifically - the century and a half old legal dogma. Abortion is only allowed when it is necessary to save a mother's life. Otherwise the mother can be jailed from anywhere between 3 to 7 years and the care-provider can be jailed for 10 years.
This means that rape victims cannot get an abortion. Nor can mothers with mental and intellectual disabilities. Or mothers carrying fetuses with severe health complications.
This law may have cost Sonia her life. Sonia had hopped from an NGO run hospital in Keraniganj to a shady back-alley clinic, to get a clandestine abortion done. Extrapolating from other such incidents, it can be assumed that the first clinic refused to terminate a 4-month-old fetus.
“We asked our aunt, who is a midwife, to refer us to a place and she took us to a clinic she's worked with,” says Humayun, her husband. “They promised that we would be able to complete all procedures within Tk 10,000.”
“Sonia was in the operation theater when the doctor suddenly came out and told me that I need to get an ambulance and take her to Dhaka Medical immediately. It all happened so fast I don't exactly know what went wrong,” shares Humayun. He broke down in a bout of tears.
The criminalisation of abortion has led to the rise in a procedure called menstrual regulation (MR).
“The procedure can be done in two ways – using a technique called manual vacuum aspiration or using a combination of drugs,” says Altaf Hossain, one of the authors of the Guttmacher study and the director of BAPSA.
Neither method requires proof of pregnancy thus keeping the mother safe from prosecution. Abortion Policies: A Global Review, which is a country-wise breakdown of abortion laws, states that MR is an exception in Bangladesh because there is no requirement to establish pregnancy first. Criminal law requires that proof of pregnancy must have been obtained for an abortion to be prosecutable.
The drugs used are a duo called mifepristone and misoprostol. They were legalised in 2012 by the Directorate General of Drug Administration and can be taken for up to nine weeks after a missed period. The other method commonly uses manual vacuum aspiration to empty out the contents of the uterus.
The practice of MR was made popular by an initiative of International Federation of Gynecology and Obstetrics between 2006 and 2011. The large-scale project was undertaken with the help of the Swedish government and specifically targeted abortion.
On the other hand, one of our largest donors, USAID, has shown reluctance to fund abortion interventions in recent history. Searching through the grants database website of the US government, we can take two of the recent grants as examples.
In 2009, USAID was offering $13 million for HIV prevention strategies, but the announcement clearly mentioned that not a cent will go towards any type of initiative about abortions – not even campaigns or communication strategies. Interestingly though, “Epidemiologic or descriptive research to assess the incidence, extent or consequences of abortions,” was allowed – sending the implicit message that research about abortion that can be used to argue against it is totally fine.
Another USAID grant from 2014 focusing on reproductive and maternal health softened up a little to include strategies providing post-abortion care. It still refused to fund abortions directly, but agreed to target the health-care needed after.
Barriers to getting MR
Here's the catch however - MR is only provided to women until their first trimester. This is not something a woman whose fetus has been diagnosed with a mortal complication later on in the pregnancy can use. Our abortion laws prevent a large population of women from making the choices they believe are right for themselves and their babies. The Guttmacher study says that, a majority of the 105,000 women who were refused MR in 2014 were turned away because their pregnancy was too advanced.
The fact that our women's only path of recourse has a time limit is not made any simpler by the fact that not a lot of people even know about MR. The study found that only about half of all married women know that this can be done and that it is available at about 40 percent of all public hospitals.
Clearly, Humayun and his late wife Sonia didn't know it either. Not knowing who to go to get an MR is one of the reasons there are so many clandestine abortions not overseen by a medical professional in the country.
“We found that the number of patients seeking post-abortive care for haemorrhage has gone up to 48 percent in 2014,” says Hossain. That is double of what it was four years ago.
Even women who know about MR and are eligible have to deal with intense social and psychological barriers in getting one.
“When a woman comes to receive an MR, she faces a lot of questions including that of her marital status. These are not a requirement for MR, but still common practice,” says Ubaidur Rob, the country director of Population Council, who has been in this sector for 25 years.
They choose instead to secretly swallow the pill that will make them miscarry.
“Ever since the drug combination became legalised, more women are choosing to use it since they can take it at home,” says Hossain. The problem, however, is that they are choosing to take it without medical supervision.
The drugs are available in most pharmacies, he says. “There are eight companies producing this, and pharmacists sell it over-the-counter with no consideration about whether the user will take it safely or not,” he argues. They don't even check how far along the pregnancy of the user is.
The drug is also relatively cheap costing around Tk 350, he adds.
“In addition, MR is a surgical method and women may be afraid of pain,” asserts Hossain. The drug has none of that.
The underutilisation of MR facilities is also another aspect clearly portrayed by the Guttmacher study. Only around half of the facilities that can do an MR actually provided the service. While part of the reason for this is that not many women come seeking the service, the social stigma when it comes to pregnancy and sex plays a more crucial role. In one of their earlier studies, Guttmacher found that around half of the professionals who were not providing this government sanctioned service were doing so because of religious and social reasons.
Around 27 percent of them were turned away because they were childless and 6 percent weren't given MR because they were unmarried.
Similarly, when women were asked why they don't choose MR, a vast majority of women cited religious and social stigma as the primary reason. The same proportion also said that objections by the husband and family also stopped them from getting an MR.
This shows that what a woman chooses to do with her body - have sex, have babies, not have babies - is not recognised as a right.
Time and again, abandoned infants are discovered. The media covered around twenty such cases in the last few years. Most of them were alive and thrown into dustbins. Public sentiment is usually along the lines of “how could a mother do this?” The fact is - if a mother gets criminalised for wanting to end a pregnancy, what other choice is left?
When Sonia's husband Humayun was asked why they were choosing to have an abortion he gave two different accounts. To the reporters in DMCH a weeping Humayun broke down and said they had eloped without telling their parents and so were not planning on getting pregnant. When I spoke to him a month later, he said that Sonia had travelled on a bus and was bleeding somewhat. They were advised to terminate the pregnancy. Either way, whether it was by choice, or by necessity that they had made the decision, it cannot be denied that her death is a failure by the system to allow mothers the right and the means to do what they want with their body.