Women's Abortion Seeking Experience in Rural Chakwal, Pakistan by Harneet Kaur Chahal A ...

140 Pages·2015·1.69 MB·English

by  Harneet Chahal

Women’s Abortion Seeking Experience in Rural Chakwal, Pakistan
by
Harneet Kaur Chahal

A thesis submitted in partial fulfillment of the requirements for the degree of

Master of Science
in
Global Health

Department of Public Health Sciences
University of Alberta

©Harneet Kaur Chahal, 2015
Abstract
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 non-
governmental 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.

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Preface
This thesis is an original work by Harneet Chahal. This research project, of which this thesis is a part of,
received ethics approval from the University of Alberta Research Ethics Board, Project Name “Abortion
seeking behavior among rural women in Chakwal, Pakistan” No. Pro00040576, 7/16/2013.

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Dedication
To the women of Chakwal.

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Acknowledgement
Completing this degree would not have been possible without the love, support and guidance of my
advisors, peers, family and friends. I am extremely grateful to my thesis supervisor, Dr. Zubia Mumtaz,
who provided me with immeasurable support and guidance throughout my Masters. I greatly admire the
passion and dedication she invests in her work and hope to apply the same tenacity in whatever steps I
take in the future. I would also like to extend my gratitude to my research assistant Zakia, to Sarra and to
Afshan Bhatti for not only supporting me throughout my field work, but for welcoming me into their
home and adopting me as nothing short of family. Thank you to my supervisory committee member, Dr.
Arif Alibhai, who provided valuable suggestions and insight as I worked through my thesis. Thank you to
the School of Public Health, my peers and others who have shared this steps with me, and offered a
compassionate ear when things felt overwhelming or stressful. My deepest gratitude to my mother and
father for their love and patience which allowed me fully dedicate my time to my Masters. And of course
a huge thank you to my sisters and best friends, Guna and Neesha, whose ability to make me laugh and
smile through any challenge allowed me to persevere. And last but certainly not least, thank you to my
love Mandeep, for joining me on this journey and pushing me to work harder than I had ever thought
possible. I could not have made it this far without you.

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Table of Contents
Abstract……………………………………………………………………………………………………..ii
Background………………………………………………………………………………………...ii
Methods…………………………………………………………………………………………....ii
Results…………………………………………………………………………………………..…ii
Conclusions………………………………………………………………………………….........iii
Preface……………………………………………………………………………………………………...iv
Dedication………………………………………………………………………………………………..…v
Acknowledgements…………………………………………………………………………,,,…………....vi
List of Tables………………………………………………………………………………………….…....x
List of Abbreviations……………………………………………………………………………………....xi
Chapter 1: Introduction and Literature Review ………………………………………………………..…..1
Introduction………………………………………………………………………………….…......1
Literature Review……………………………………………………………………………...…..3
Conclusions……………………………………………………………………………………......8
Research Questions…………………………………………………………………………….....10
References………………………………………………………………………………………...11
Chapter 2: Methods......................................................................................................................................18
Methodology...................................................................................................................................18
Study Setting...................................................................................................................................18
Participants......................................................................................................................................20
Participants- Patients..........................................................................................................20
Participants- Providers.......................................................................................................22
Methods...........................................................................................................................................23
Research Assistant..........................................................................................................................25
Analysis...........................................................................................................................................27
Rigor...............................................................................................................................................28
Ethics...............................................................................................................................................29
References.......................................................................................................................................30
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Chapter 3: Manuscript 1, Abortion services in Pakistan: a grey zone and compromises............................32
Conclusion......................................................................................................................................36
References.......................................................................................................................................37
Chapter 4: Manuscript 2, Misoprostol and abortions...................................................................................41
Abstract............................ ..............................................................................................................41
Introduction.....................................................................................................................................41
Methods...........................................................................................................................................43
Findings...........................................................................................................................................46
Women seeking abortions to limit their fertility ...............................................................46
Misoprostol, allowing women to meet their fertility needs...............................................49
Reconciling the pursuit of abortions..................................................................................52
Discussion.......................................................................................................................................53
Conclusion......................................................................................................................................60
References.......................................................................................................................................61
Chapter 5: Manuscript 3, Ideology trumps: healthcare providers a barrier to safe abortion services..........71
Abstract...........................................................................................................................................71
Introduction ....................................................................................................................................72
Methods...........................................................................................................................................74
Findings...........................................................................................................................................76
Provider views of abortion ................................................................................................76
Impact of provider views on their provision of abortion services.....................................79
Discussion ......................................................................................................................................83
Conclusion......................................................................................................................................88
References.......................................................................................................................................89
Chapter 6: General Discussion and Conclusion...........................................................................................95
Discussion ......................................................................................................................................95
Conclusion....................................................................................................................................100
Limitations....................................................................................................................................101
References ....................................................................................................................................103
Bibliography ..............................................................................................................................................107
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Appendices ................................................................................................................................................123
Appendix 1: Consent form, interview...........................................................................................123
Appendix 2: Consent form, focus group.......................................................................................125
Appendix 3: Research Assistant Confidentiality Agreement.......................................................127
Appendix 4: Question guideline (interviews and focus group discussions, patients and
providers)......................................................................................................................................128

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List of Tables

Table 1- Characteristics of patient participants...........................................................................................20
Table 2- Healthcare providers in the Rahnuma clinic in Chakwal..............................................................21

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