Silent state violence
So long as abortion remains illegal, poor women will continue to die. - By Dr Aruna Uprety

I started working as a medical officer at the Prasuti Griha in Thapathali about 14 years ago. At about five pm one evening in the emergency ward, some three months after I had started work at the hospital, a 40-year-old woman was brought in by her husband. She was in very critical condition. She was pale as a sheet and had a high fever.

I could not diagnose what was wrong with her and requested a senior doctor to have a look. The senior gynaecologist examined her and said she had a ‘septic abortion’. The woman was treated immediately, and as she needed a blood transfusion, we asked her husband to get blood for her. The woman’s condition was deteriorating by the minute. After 20 minutes, her husband returned with a packet of blood. But the woman was breathing her last and after ten minute, despite our best efforts, she died.

I remember this incident in minute detail because this was the first death I had witnessed in my young medical career. Later on, we spoke with the husband and he told us the story. The woman who died was the mother of five. When she got pregnant for the sixth time, neither she nor her husband wanted more children. But they did not have enough money to go to a doctor for an abortion, and so they decided to visit a woman in a nearby village they had heard could terminate pregnancy.

According to the husband, the old woman had given his wife something to eat and then inserted herbs into her vagina. The foetus was expelled after 24 hours, but the woman started running a high fever. They hoped the fever would soon subside and bleeding would stop. But she didn’t get any better. The husband consulted the old woman again, but she brushed him off, saying his wife would be better soon. She started getting worse. By the third day after the abortion, the woman was bleeding heavily and had lost consciousness. With the help of other villagers, the husband brought his wife to the maternal hospital, only to have her die before his eyes.

The situation has not changed much since. Women are still dying because of illegal, clandestine, back-street abortions. If they manage to survive the sloppy, often ignorant and dangerous procedures, they often suffer from diseases and disorders for the rest of their lives. The UN’s 1996 Human Development Report says that Nepal’s Maternal Mortality Rate (1,500 women per 100,000 live births) is one of the highest in the world. Many people disagreed with this data and said that the situation was "not so bad." Around the same time, Dr Rita Thapa, a public health specialist formerly with the WHO, presented a paper in a workshop organised by a Nepali NGO on gender issues and women’s health in Nepal that said: "About 50 percent of maternal deaths in Nepal are due to abortion-related complications."

Death related to badly performed abortions has not declined in recent years, and will not in the near future, because Nepali law does not allow women to have abortion under any circumstances, even if the pregnancy is result of rape or incest. Nepali law does not allow this basic, some might say common-sense law, but instead suggests vengeance: a woman may kill her rapist within one hour of the rape.

What choices does this leave the woman? Should she continue the pregnancy, or see it to term, and then kill the child after it is born if it is the result of rape? Should she go to an old woman or a quack to terminate the pregnancy, and possibly be killed herself, or at best live with the resultant complications, maybe even for the rest of her life? Whatever happens, the woman suffers.

If you do not believe me when I say that abortion (mostly illegal and unsafe abortion) is the cause of high maternal morbidity (diseases pattern) and maternal death, consider this data of hospitals from Kathmandu and Dharan—in the five years from 28 May 1995 to 28 May 2000 in the maternity hospital in Prasuti Griha total gynaecological admissions were 16,150. Of these, 6,671 (about 41.3 percent) were abortion-related. Of course, not all abortion-related complications examined were because of induced unsafe abortion. Still, Dr Sarshwati Padhey director of Prasuti Griha says, " Many women come to hospital with abortion-related complications. And most of them are because of abortion conducted by unqualified personal and by unsafe method."

Grassroots public health organisations and women’s welfare groups realise that there is a problem and are doing their best to see find solutions within the existing situation. The Nari Bikas Sangha and Kathmandu’s Centre for Research on Environment Health and Population Activities brought together people last month to discuss exactly this. Dr Dhruba Uprety, a gynaecologist from BP Koirala Institute of Medical Science’s Dharan Medical College presented a paper asserting that: "Unsafe abortion is responsible for 13 percent of maternal mortality in the world. In some developing countries, it is responsible for more than 50 percent of maternal deaths. This statement is true in our context. In the BP Koirala Institute of Health Sciences (BPKIHS) hospital in Dharan unsafe abortion is the biggest cause of maternal mortality. It accounts for 44 percents of maternal death in the last four years and 58 percent of maternal deaths in the year 2057 (April 2000- April 2001)." Dr Uprety’s conclusions were based on a study on septic abortion conducted in the Department of Obstetrics and Gynaecology at the BPKIHS hospital from April 2000-April 2001.

After Dr Uprety presented his paper, my first comment was: "All my ideas that when a woman with abortion-related complications comes to the hospital (and specially to a the highly specialised hospital like that in Dharan), she is lucky, because she does not need to fear for her life. But this study shows that most of the time women are brought in such a critical condition, that even specialists, modern medical facilities and modern medicine can not save their lives."

In the 21st century our women are dying because the law does not allow them to have abortions. But, only illiterate, poor women who do not have access to qualified health personal to perform (illegal) abortions are dying. What I conclude from this is that if you have money and you can afford go to any doctor in a private clinic and get safe, if illegal abortion, you will not die or suffer any problems. Is our state is responsible only for citizens who are rich and knowledgeable, but not for those who are voiceless.