When Amin Masih got the phone call in February, he went to the hospital thinking Rabia, his 27-year-old daughter, had been injured while riding through the streets of Lahore on the back of a motorbike. After he arrived outside the emergency room, he found her on a stretcher. Rabia had been brought in by her boyfriend Ijaz who, uninjured, insisted there had been an accident. At that point, Rabia was already dead.
At first, Amin accepted that she had been killed in a crash. He had known Ijaz was involved with his daughter for about two years, and he had spoken to him about the pair’s potential engagement. The families lived in the same area, a Christian enclave in Lahore, Pakistan’s second-largest city. They knew all the same people, so it was best to settle the matter quietly. And Rabia was gone, after all, so what was the point of dwelling on what happened?
Rabia’s family arranged for an ambulance to bring her home, and it wasn't until her aunt started washing the body for burial did something feel amiss. The marks and swelling on the corpse were abnormal, and it was strange Ijaz could have survived a motorbike accident unscathed. The family filed a police report, opening an investigation into the incident. An autopsy confirmed a different cause of death than a motorbike accident: criminal abortion and its complications.
Rabia’s postmortem report shows an abortion gone horribly wrong—something not uncommon in Pakistan, where safe abortion care is often limited to those who can find it and afford it. Across all segments of society where access to health services oscillates wildly due to class and connections, there's a common theme: Getting an abortion is not easy, and in the worst cases, it can be disastrous.
Pakistan has one of the highest abortion rates in the world; around 50 are done per 1,000 pregnancies, according to one of the most comprehensive reports on the subject done in 2012. Many of them are administered by untrained providers despite Pakistani law providing some leeway for legal abortions to save a person’s life and provide necessary treatment early in pregnancy. In this way, Pakistan allows for more liberal interpretations than some other Muslim majority countries.
An autopsy confirmed a different cause of death than a motorbike accident: criminal abortion and its complications.
Even still, information about where to get an abortion gets passed around like a game of telephone said Sana, a 33-year-old mother of four, who got the operation done at a private clinic in Rawalpindi after an extensive search for providers. Going to a hospital wasn’t an option, Sana, whose name has been changed to protect her from possible repercussions, thought. She had already asked her former classmate, a gynecologist, who told her it was illegal.
It’s not surprising that even doctors don’t know what’s allowed and what’s not, Sadiah Ahsan Pal, a well-known gynecologist in Karachi, told VICE World News. Pal said topics related to sexual health were generally brushed aside when she was studying gynecology or discussed with sinful connotations attached. “In medical school, we weren’t taught. And when we were taught it was in such a way that at that age as a girl it was very unpleasant,” she said. “And most girls in my class would just walk out of that class the way it was being taught. It was very disrespectful.”
According to the Guttmacher Institute, a research organization that has done numerous studies on sexual health in Pakistan, around 3.8 million unintended pregnancies take place there every year. And since contraceptive use is not widespread—only 34 percent of married women use it—many rely on abortions as a form of birth control. Sana was getting her second abortion that day at the clinic because, she said, her “family is complete.”
Despite some healthcare providers openly recognizing the need for safe abortion services in a country where many people lack access to the most basic forms of birth control, broaching the topic openly still carries a degree of moral hazard. Some providers refuse to perform the operations while plenty of others who do it actively claim they don’t. As a result, people learn where to seek the service through word of mouth and trial and error.
According to Rabia's postmortem report, her cause of death was a criminal abortion and its complications. (Courtesy of Betsy Joles)
A common thread in their stories is how fear of retribution from family, community members, and doctors remains a limiting factor to safe abortion care. Rabia’s family says they didn’t know she was pregnant and are reluctant to admit she died from an abortion, in part because her injuries were so severe. Getting pregnant out of wedlock is also a major scandal in Pakistan. If they had known she was pregnant, Rabia’s family told VICE World News they would have insisted the couple get married.
They do, however, want to make public the extent to which her body was brutalized, because, in addition to a failed abortion, hers is now a murder case against whoever performed the operation so poorly. Rabia’s postmortem report lists injuries caused by blunt means, resulting in internal bruising, a lacerated cervix and damaged large intestine, as well as perforation of the uterus, which the forensic examiner has written led to hemorrhagic shock.
Since contraceptive use is not widespread—only 34 percent of married women use it—many rely on abortions as a form of birth control.
Despite the family’s skepticism, an investigator on the case, Tassaduq Khokhar, said all evidence—including the postmortem report showing retained fetal parts—suggests this was a failed abortion. Ijaz, the boyfriend, confessed to his involvement in ending the pregnancy. His paternal aunt, who Khokhar said investigators believe performed the operation in her apartment, is also a suspect.
DNA tests are currently underway for items found in Ijaz’s aunt’s apartment, and on the fetus. If convicted, Khokhar said Ijaz and his aunt could face life imprisonment or death under the 302 section of Pakistan’s Penal Code.
“The problem here is people don’t want to say what they are doing,” Dr. Rubina Sohail, a professor of gynecology and obstetrics at Services Institute of Medical Sciences, a teaching hospital in Lahore, told VICE World News. Sohail said doctors assess situations on a case-by-case basis, and certain circumstances require them to confer as a group.
It is possible to make arguments for exceptional cases; Sohail cited an example of a young girl she suspected had been impregnated by someone in the family that was allowed to receive an abortion. But for most general requests, the hospital has to refer the patient to other providers. Sohail emphasizes to hospital staff that they must advise women in need even if they don’t feel comfortable dealing with abortion cases themselves. But addressing deeply held beliefs can be an uphill battle. “You cannot change the mindset of everybody,” she said.
Because laws on abortion are vague, the decision to provide an abortion or not often comes down to a provider’s personal or religious beliefs, which for many, makes the prospect unthinkable.
Yasmeen Soomro, a community midwife in western Karachi, described her opposition to abortion in moral terms. In Urdu, she used the verb zaya karna when she talks about getting rid of a fetus, which translates to “waste.” She has no time for women who can’t prevent their own pregnancy, she said, and looking after them if they’ve gotten pregnant by accident is not her job.
It’s a matter of life and death, but many of the most qualified doctors aren’t willing to do the operation.
Providers supported by the private sector or humanitarian organizations are encouraged to provide care and counseling as needed, but even those allowed have their reservations. “It’s not that the hospital administration does not allow us to perform abortions, we don’t do them ourselves. We are afraid of God,” said Rukya Bibi, a lady health worker, the designation for a community-based women’s healthcare provider, at a small women’s clinic near Sargodha.
Reluctance to do abortions, or reluctance to admit to doing them, is also about appearance. In insular communities, where terminating pregnancies early can bring shame and judgment on families, providers—though many of them are well known and even viewed as necessary in areas that lack healthcare facilities—are precariously positioned to do their work.
One midwife who has been practicing for 28 years in her small two-room clinic on the outskirts of Karachi, adamantly said that she doesn’t deal with abortions, despite members of the community telling VICE World News she does. According to her, she’ll advise people on pills they can take, but she won't perform the dilation and curettage procedure because she is afraid of getting in trouble.
It’s a matter of life and death, but many of the most qualified doctors aren’t willing to do the operation, a staff nurse in Baldia Town in Karachi told VICE World News. In her previous job in a government hospital, she frequently saw women turned away for abortion services and others who came to the hospital bleeding after their abortion attempts had failed.
Yet even providers who are personally against abortions recognize large segments of Pakistani society can’t afford or access birth control, which leads to unwanted pregnancies—which they also can’t afford. Mariyam Sheikh, one doctor at a basic health unit in Moach Goth in Karachi, said women in her area don’t even go to healthcare centers when she refers them there because, in many cases, they can’t pay for the bus ticket.
There’s a web of other organizations and private providers that take on abortion operations since public hospitals in Pakistan are more restrictive. These range from pricy private clinics in cities to bare-boned setups run by midwives or traditional birth attendants in less developed areas.
Mariyam Sheikh, one doctor at a basic health unit in Moach Goth in Karachi, said women in her area don’t even go to healthcare centers when she refers them there because, in many cases, they can’t pay for the bus ticket.
Further efforts to make information about abortion more accessible do exist, but they are limited. Saba Ismail, an activist and co-founder of Aware Girls, a women’s rights organization, started an abortion hotline to help people learn about their options back in 2010.
“We were straightforward: this is an abortion hotline and women should contact it,” Ismail told VICE World News. Now, more than a decade after the hotline started, the same questions of accessibility remain. “If they don’t have this information, how will they end up?” asked Ismail. “They will end up in some backstreet abortion clinic, which are so unsafe.”
Safe abortion advocates in Pakistan also hold trainings for providers to address any biases they might have about the procedure. The organizations providing these trainings said many doctors don’t even know abortion is legal until they attend the sessions, and some don’t realize how many prejudices they hold until they’re asked to confront them.
Some private providers have also tried to rebrand abortion services in a way that makes them less daunting. In Karachi, there’s an abortion clinic that resembles an upscale salon replete with mood lighting and reclining chairs in the room where women rest after getting the operation. The organization that partnered with the clinic said it was trying to make the service more accessible for urban working people to discourage them from ending pregnancies in ways that could kill them.
The month before Rabia’s death, there was a case in Lahore of a student, Maryam Fatima, whose body was deposited at a hospital after a failed abortion. Current statistics on deaths from clandestine abortions are hard to come by in Pakistan, but stories like Maryam’s are common enough to make Rabia’s cousin, Abeer Kanwal, nervous that her case will be lumped in with the others and not investigated thoroughly.
Rabia’s family still has doubts about “everything, basically,” Kanwal said.
Abeer Kanwal, 25, Rabia's cousin sits with a young family member in her uncle's home in Lahore. (Courtesy of Betsy Joles)
Investigations in Pakistan can be a lengthy process, and not all of them lead to a conviction. Rabia, who worked as a beautician, was also the main breadwinner in her household, and for a family of limited means, getting a lawyer to see the case through until the end will be costly. Still, they hope the investigation will turn up answers to some of their lingering questions about the severity of her injuries and how they occurred.
“Every other day we hear these kinds of stories. But when this happened to us, it totally broke us,” Kanwal told VICE World News. But even after her death, Rabia’s and her family’s reputation is on the line, and to preserve it— like with most abortion cases in Pakistan—their inclination is to keep quiet.
“We talked about it earlier very much,” Kanwal said. “But now we are letting it be.”
This work was supported by the Pulitzer Center.