By Zofeen Ebrahim
With its latest hotline a surefire hit, the non-government group Aware Girls could not be any happier.
"We received about 30 such calls in just under a month," says 24-year-old Gulalai Ismail, chairwoman and founder of the organisation. "And we have not even started advertising!"
But the news that the hotline is helping women use the drug misoprostol to induce abortion at home is worrying several reproductive health experts. Zulfikar Bhutta, paediatrics department head at the Aga Khan University Hospital (AKUH), even says that the venture may well "derail" the main use of the drug – to reduce the risk of post-partum haemorrhage – in Pakistan.
"I was not aware that this use (of misoprostol) is so brazenly being promoted in Pakistan, when even developed countries have balked at such use and advertisement," says Bhutta, who is also co-chair of Countdown to 2015, a global scientific and advocacy group tracking progress in maternal, newborn, and child health. "You can imagine that in the hands of untrained staff, this can be problematic as well."
Misoprostol, a World Health Organisation-approved drug, is also more commonly used in the prevention and treatment of gastric ulcers.
Medical experts, though, have acknowledged that the drug can induce miscarriage – something that has attracted organisations and women’s rights advocates who want to help lessen the risks women go through when they decide to terminate their pregnancies.
There are 30,000 pregnancy-related deaths annually in Pakistan. The latest Pakistan Demographic and Health Survey (2006-2007) says about 5.6 percent of these deaths are abortion-related, but experts say the figure could be as much as 15 percent.
A 2004 national study conducted by the Population Council also says that there are 900,000 unsafe abortions each year in Pakistan, with some 197,000 women brought to hospital with post-abortion complications.
With only 22 percent of married women using a modern method of family planning, the Population Council report points out that abortion is increasingly resorted to for ending unplanned births. In fact, the typical profile of a woman turning to abortion in Pakistan is that of a married woman with three children.
Laws covering abortion are ambiguous in this predominantly Muslim nation, where public hospitals shy away from performing it. Social norms hinder women from openly seeking to terminate their pregnancies. Abortions are thus often performed clandestinely in unhygienic conditions, resulting in high morbidity and mortality.
For many women’s rights advocates here, misoprostol comes close to being a lifesaver.
A press statement by Women on Waves, one of the international groups supporting the misoprostol hotline, asserts that using the drug "is far safer than the unsafe surgical or traditional methods that women will use when desperately trying to end an unwanted pregnancy and has the same health impact as a spontaneous miscarriage".
Ismail, meanwhile, says of the new hotline: "It promises complete confidentiality in a country where seeking abortion is a taboo. Most women do not have access to the Internet, and are not mobile and often do not access health centres. But everyone has a cell phone these days."
The hotline was launched on Jun. 25 under the project ‘Sahailee’, which is Urdu for ‘female friend’. Established by a coalition of organisations, among them Aware Girls, it is now running in Karachi, Peshawar, and Lahore.
Before the launch of ‘Sahailee’, hotline operators were trained for three weeks before they started handling calls, during which they give information about how to use misoprostol, as well as about its after-effects that include nausea, vomiting, diarrhoea, weakness, headache, chills and fever, and dizziness.
Hotline operators are also in reproductive-health issues and family planning, but do not usually refer clients to doctors or counsellors.
"It was emphasised that the (hotline) counselors could not impose their personal biases and moral values on the caller," says Ismail. "The final decision to abort or not to should remain with the woman caller."
Information about misoprostol, an over-the-counter drug that is relatively cheap costing about 10 rupees per tablet or 11 cents, is also not given right away. Says a Lahore- based hotline operator: "We have a set of questions that we ask the caller before we part with the information. (And we) always tell our callers that it is advisable to take the drug in the presence of a skilled birth attendant."
Samrina Hashmi, a former Pakistan Medical Association official, calls the hotline "a very good step", noting in its lack of face-to-face contact that lends utmost confidentiality.
Obstetrician-gynaecologist Nighat Shah says of the hotline: "I hope it reaches the women who seek help."
In the absence of mifeprisitone, an abortifacient, misoprostol is the next best option, she says, adding, "We save mothers, whatever, however."
But wariness toward the hotline persists. The president of the National Committee on Maternal and Neonatal Health, Prof Sadiqa Jafarey, says: "As a clinician, I would be very cautious of advising a woman without knowing her history or doing a physical check-up."
Midwifery Association of Pakistan President Imtiaz Kamal worries about the distribution of "miso like candy".
"These over-enthusiastic activists sometimes do more harm than good to a cause," says 86-year old Kamal, who says the drugs need to be administered under a trained healthcare provider’s supervision.
But a determined Ismail says, "We are there to save women’s lives. The law gives us permission. In fact, if the government provided safe abortion services to women in public hospitals, many women may be alive today."