Background: In Pakistan, abortions occupy a highly contentious space. Legal and religious restrictions
have created a substantial social stigma around this procedure. Irrespective of this restrictive environment
however, women continue to pursue abortion services often turning to clandestine means in order to keep
the procedure a secret. While this does allow women to maintain privacy, these unsafe services greatly
elevate risks of maternal morbidity and mortality. Nonetheless, the topic of unsafe abortion and its impacts
on maternal health remains understudied. To gain a better understanding of the abortion landscape in
Pakistan, this study investigated women’s abortion seeking behavior in the rural setting of Chakwal,
Pakistan. Specifically, this study explored why demand for abortions has increased, and whether providers
are willing to meet the increased demand.
Methods: A focused ethnography was conducted in Chakwal, Pakistan from September to December of
2013. Participants were recruited from the Rahnuma Family Planning Association of Pakistan, a nongovernmental
organization that provides family planning and reproductive health services, including
abortions. Twenty three in-depth interviews were conducted with women seeking, or that had received an
abortion and fourteen in-depth interviews were conducted with the facility’s healthcare providers. One
focus group discussion was conducted with providers.
Results: Findings revealed women had a strong desire to control fertility, but this need was not being met
through contraceptives. Where confronted with an unplanned pregnancy women turned to abortions,
specifically through the drug misoprostol to limit their fertility. The ease of this abortifacient’s use not only
enabled an increased reliance on abortion to terminate unplanned pregnancy but possibly as a preferred
means of fertility regulation. Furthermore, safe abortion services were found to exist within a clinical
setting. Two NGO’s were providing safe, clinical abortion services through trained providers. But at the
interface between patients and the health system, providers emerged as a key barrier in women’s ability to
access safe abortion services. Provider’s negative views of the procedure and a system of patronage led to
restrictive provision of this service.
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Conclusions: To support women’s access to safe abortions we recommend training mid-level providers to
safely administer misoprostol within women’s homes, as part of their existing home based care. Improving
contraception uptake will also be important to prevent abortions in the first place. Furthermore, there is a
need for greater attention to be given in hiring providers who are willing to conduct abortions, to improve
providers counseling skills, and expand family planning services.