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Better family planning and counselling needed to reduce unsafe abortions: Local study 

20 Dec 2021

BY Ruwan Laknath Jayakody  Until the laws for the legalisation of abortion for more conditions are enacted in Sri Lanka, family planning services and counselling should be offered especially in pre-marital, pre-pregnancy and post-pregnancy periods in order to reduce the number of unsafe abortions.  This recommendation was made in an original article on “Abortion and its legalisation: An overview of the opinion of doctors in the Colombo South Teaching Hospital, Kalubowila” which was authored by R.P.A. Dinethri, N. Roshanthan, M.A.P.A. Perera, W.D.O. Wasana and A.A.B.S. Perera (undergraduates), Prof. M. Vidanapathirana (attached to the Sri Jayewardenepura University’s Medical Sciences Faculty’s Forensic Medicine Department), Senior Prof. K. Wijewardena (attached to the same latter Faculty) and the Colombo University’s Demography Department’s Professor Emeritus K.A.P. Siddhisena and published in the Medico-Legal Journal of Sri Lanka 4 (1) in December 2016.  Abortion is defined in the “Mosby medical dictionary's eighth edition” as the spontaneous or induced termination of pregnancy before viability. According to Section 303 of the Penal Code, miscarriage is the termination of pregnancy before its natural expulsion, and therapeutic abortion can only be performed when the mother’s life is in danger. Per Section 303, anyone voluntarily causing a woman with a child to miscarry (terminate pregnancy) is subject up to three years of imprisonment and/or the payment of a fine, unless (and only when) the miscarriage was caused in good faith (and required) in order to save the life of the mother.  However, safe abortions, as noted in P.A. Lohr, M. Fjerstad, U. de Silva and R. Lyus’s “Abortion”, do not cause either long-term mental or physical problems. The World Health Organisation’s (WHO) “Safe abortion: Technical and policy guidance for health systems. Second edition” recommends that this same level of safe and legal abortions be made available to all women globally. Morbidity and mortality due to unsafe abortions are, Dinethri et al. observed, a global issue. Unsafe abortion is defined in the WHO’s “Unsafe abortion: Global and regional estimates of the incidence of unsafe abortion and associated mortality in 2008. Sixth edition” as a procedure for terminating an unintended pregnancy which is carried out by persons lacking the necessary skills and/or in an environment that does not conform to the minimal medical standards. According to S. Sedgh, S. Singh, I.H. Shah, E. Ahman, S.K. Henshaw and A. Bankole’s “Induced abortion: Incidence and trends worldwide from 1995 to 2008”, 50% of the estimated 44 million abortions performed globally each year are performed unsafely, and they, per I. Shah and E. Ahman’s “Unsafe abortion: Global and regional incidence, trends, consequences and challenges”, result in approximately five million hospital admissions and 47,000 maternal deaths per year globally, with 13% of them, as per D.A. Grimes, J. Benson, S. Singh, M. Romero, B. Ganatra, F.E. Okonofua and I.H. Shah’s “Unsafe abortion: The preventable pandemic”, being due to unsafe abortions. In many parts of the world, as Dinethri et al. mentioned, there is controversy over the moral, ethical, and legal issues of abortion with those who are against abortion generally stating that an embryo or foetus is a human with the right to life and therefore compare abortion to murder while those who support abortion rights emphasise a woman’s right to decide on matters concerning her own body. Abortion is legalised in many countries for many indications other than when the mother’s life is in danger, such as when the mother’s health is in danger, pregnancy following rape or incest, foetal anomalies and contraceptive failure (in India, it is legal up to 28 weeks of pregnancy under the Medical Termination of Pregnancy Act). It is estimated that of the 210 million pregnancies that occur globally each year, 10%, according to the United Nations “Sri Lanka: Abortion policy”, are due to the ineffective use of a contraceptive method. Rape, per Section 363 of the Penal Code is defined as “committing sexual intercourse without consent under the listed circumstances”. Incest, per Section 364A of the Penal Code, means “whoever has sexual intercourse with another who stands towards him in any of the enumerated degrees of relationships as described”.  In 1973, the Medico-Legal Society of Sri Lanka recommended that the law should be liberalised to allow abortions to be performed to prevent grave injury to the physical and mental health of the mother, in cases where the pregnancy resulted from rape or incest, and in cases where there was substantial risk that the child, if born, would suffer from severe physical or mental abnormalities. In 2011, the Sri Lanka College of Obstetricians and Gynaecologists presented a draft petition to the relevant authorities appealing to liberalise the abortion law in cases of pregnancy following incest, rape or lethal congenital anomalies. “Despite rigid Statutory Provisions, Sri Lankan women of higher socio economic status who desire to terminate their pregnancies, find little or no difficulty in getting it done. Women from the middle and lower socio income layer, however, often resort to abortions performed by back door abortionists, under primitive and unhygienic conditions,” Dinethri et al. claimed.
  1. Jayaratne’s “Maternal death surveillance and response” estimated that the 2014 maternal mortality rate was 32.03 deaths per 100,000 live births, and that of them, 12.5% related to unsafe abortions, and that today, abortion is the third commonest cause for maternal death in Sri Lanka, while the Family Planning Association of Sri Lanka estimates that there are around 1,000 abortions performed daily.
The results of various researches done in other countries reveal that the maternal death rates have been reduced with the liberalisation of abortion.  Therefore, Dinethri et al. conducted a descriptive, cross-sectional study to ascertain an overview of the opinion of doctors at the Colombo South Teaching Hospital in Kalubowila regarding abortion and its legalisation. The study population included Consultants, Senior Registrars, Registrars, Senior House Officers, Residential House Officers and House Officers. The participants were selected using the random sampling method. A self administered questionnaire was given to the participants. The responses “strongly agree” and “agree” were considered together as “agreed” while “strongly disagree” and “disagree” were considered together as “disagreed”. The socio demographic characteristics of the 207 participants included sex (104/50% females, and 103/50% males), age (122/59% above 35 years, 52/25% between 35 and 45 years, and 33/16% below 45 years), ethnicity and race (152/73% Sinhalese, 43/21% Tamil, and 12/6% Muslim), religion (146/71% Buddhist, 35/17% Hindu, 13/6% Catholic, 11/5% Islam, and two/1% atheist), marital status (142/69% married, and 65/31% unmarried), designation (Medical Officers, House Officers, Registrars, or Senior Registrars, and Consultants), years of experience (104/50% had less than five years, 53/26% had more than 10 years, and 50/24% had five to 10 years), and country of graduation (191/92% from a local university, and 16/8% from a foreign university). The three potential situations considered for the liberalisation of abortion were medical (the mother’s health being in danger and other special medical conditions), legal, and social situations and conditions. A total of 143/69% agreed and 44/22% disagreed for the legalisation of abortion for other situations. Almost all (200/97%) agreed with the existing legal indication of abortion when the mother’s life is in danger; only five/3% disagreed.  The majority agreed to legalise abortion on medical conditions (157/76% for when the mother’s health is in danger [26/13% disagreed], and 117/57% for other special medical conditions [60/29% disagreed]) and legal conditions (141/68% [38/18% disagreed]).  The majority (152/74%) disagreed with abortion on social indications (30/15% agreed).  On the opinion concerning the legalisation of abortion when the mother’s health is in danger, the majority (76%) agreed, but this finding showed no significant association with the socio demographic factors.  The four special medical conditions considered for legalisation were anencephaly (baby born without parts of the brain and skull), Down’s Syndrome (child born with an extra copy of their 21st chromosome which causes physical and mental developmental delays and disabilities), haemophilia (affects the blood’s ability to clot) and thalassaemia major (causes the body to have less than normal levels of haemoglobin [which enables red blood cells to carry oxygen], and causes anaemia, leaving one fatigued). Though the majority agreed (57%) for abortion on the above mentioned special medical conditions, the opinion of the participants on each of those special medical situations showed no significant association with the socio demographic factors. The two considered legal situations were rape and incest. When all the parameters were considered (72/71% males and 69/67% females agreed, and 30/29% males and 34/33% females disagreed; 105/70% Sinhalese, 31/72% Tamils and five/42% Muslims agreed, and 45/30% Sinhalese, 12/28% Tamils and seven/58% Muslims disagreed; 26/74% postgraduates and 115/68% non-postgraduates agreed and nine/26% postgraduates and 55/32% non-postgraduates disagreed; 104/68% with over 10 years experience and 37/71% with 10 or less than 10 years experience agreed, and 49/32% with over 10 years experience and 16/29% with 10 or less than 10 years of experience disagreed), except for the participants who were Muslims, more than about 67% agreed with abortion if the pregnancy resulted from a rape. Regarding the ethnicity factor, the difference seen in the distribution was statistically significant. However, on the opinion regarding the legalisation of abortion on legal situations such as incest, about two third agreed with abortion but there was no significant association between their opinion and the socio demographic factors. The three social conditions considered for the legalisation of abortion were contraceptive failure, family health being in danger, and the family having a low income level and a high number of children. Most disagreed with abortion in contraceptive failure (20/20% males and 16/16% females agreed and 82/80% males and 86/84% females disagreed; 23/15% Sinhalese, 12/28% Tamils and one/8% Muslim agreed, and 126/85% Sinhalese, 31/72% Tamils and 11/92% Muslims disagreed; five/15% postgraduates and 31/18% non-postgraduates agreed and 29/85% postgraduates and 139/82% non-postgraduates disagreed; 21/14% with over 10 years experience and 15/28% with 10 or less than 10 years of experience agreed, and 130/86% with over 10 years of experience and 38/72% with 10 or less than 10 years of experience disagreed). However, 38/72% with more than 10 years of experience and 130/86% with less than 10 years of experience disagreed about performing abortion in contraceptive failure and this difference was found to be statistically significant. Similarly, the majority disagreed with abortion when the family members health is in danger. Further, 37/73% with more than 10 years of experience and 134/89% with less than 10 years of experience disagreed and this difference was found to be statistically significant. Moreover, most disagreed with abortion when the family had a low income and a higher number of children. When ethnicity was concerned, 135/88% Sinhalese and 100% Muslims disagreed. However, 27/77% postgraduates and 155/90% non-postgraduates disagreed and this difference was found to be statistically significant. When all the parameters were considered (advantages [137/66% agreed, 17/8% had no idea, and 53/26% disagreed] of reducing the maternal mortality rate [154/75% agreed, 17/8% had no idea, and 34/17% disagreed] and reducing unwanted pregnancies [138/68% agreed, 30/15% had no idea, and 36/17% disagreed], and the disadvantages [135/65% agreed, 32/16% had no idea, and 40/19% disagreed] of misusing the legal abortion [167/81% agreed, 19/9% had no idea, and 14/7% disagreed] and the reduced usage of contraceptives [77/37% agreed, 46/22% had no idea, and 74/36% disagreed]), 137/66% agreed that there will be advantages if abortion is legalised in Sri Lanka. However, 135/65% agreed that there will also be disadvantages. Further, none of the advantages or disadvantages had a statistically significant association with the socio demographic factors. Per K.R. Curwell, M. Vekemans, U. de Silva and M. Hurwitz’s “Critical gaps in universal access to reproductive health: Contraception and prevention of unsafe abortion”, by 2008, 40% of the world’s females had access to legally sanctioned safe abortions without restriction as to the reason. However, in Sri Lanka, in addition to the law, the termination of pregnancy is restricted by social norms, per P. Olsson and K. Wijewardena’s “Unmarried women's decisions on pregnancy termination: Qualitative interviews in Colombo” despite a significant number of morbidity and mortality. In this study, it was revealed that the majority of the participants agreed to legalise abortion in certain identified medical and legal situations, but disagreed to legalise abortion on identified social indications. According to the current study, when considering special medical conditions such as Down’s Syndrome, anencephaly, haemophilia and thalassaemia major, the majority had a positive attitude towards abortion in all four conditions.  With regard to the legal conditions considered in the study, nearly more than two third agreed with abortion when rape is presented as the condition. In the current study, males (71%) and females (67%) had a similar opinion regarding rape. When the ethnicity was considered, Sinhalese (70%) and Tamils (72%) agreed with abortion in the case of rape, however, the majority of Muslims (58%) disagreed and this association was found to be statistically significant. The majority of the Muslims disagreeing, Dinethri et al. ventured, may be due to their differences in cultural and religious backgrounds when compared with the other major ethnic groups, the Sinhalese and the Tamils. Moreover, according to the “Historical dictionary of Islam: Second edition” by L. Adamec, in the Muslim religious environment, performing an abortion is an anti-religious activity/haram. When incest was considered as the underlying situation, about two third agreed with abortion, but there was no significant association between their opinion and the socio demographic factors. Regarding the factor of ethnicity which showed a significant association in the condition of rape, it has however not become significant in the case of incest. “Even though these two conditions have different terminology, both of these situations are almost the same. Rape means committing sexual intercourse without the consent of a female in circumstances as described in Section 363 whilst incest means a graver type of rape where the perpetrator possesses some relationship to the victim as described in Section 364. Therefore, this difference of opinion might be due to poor knowledge among the participants about the term ‘incest’,” Dinethri et al. opined. When the social situations such as contraceptive failure, other family members health being in danger and the family having a low income and a higher number of children were considered, the majority (152/74%) disagreed with the legalisation of abortion in such social conditions. When the factor of contraceptive failure was considered, both males (82/80%) and females (86/84%) almost equally disagreed in the legalisation of abortion following contraceptive failure. Further, 38/72% with more than 10 years of experience and 130/86% with less than 10 years of experience declined to perform abortion on contraceptive failure and this association was found to be statistically significant. Therefore, when contraceptive failure presents as the condition, the disagreement of doctors with less than 10 years of experience was statistically significant. Similarly, when the factor of the other family members’ health being in danger was considered, the disagreement of doctors with less than 10 years of experience was statistically significant. Both males and females, Sinhalese (135/89%), Tamils (35/81%) and Muslims (12/100%), disagreed with seeking abortion when the family had a low income and a higher number of children. Further, 27/77% of postgraduates and 155/90% of non-postgraduates disagreed to perform abortion on the condition that the family had a low income and a higher number of children, and this association was found to be statistically significant. Therefore, when a family with a low income and a higher number of children presents as the condition, the disagreement of non-postgraduate doctors was statistically significant. According to J. Perera, T. de Silva and H. Gange’s 2004 study on the “Knowledge, behaviour and attitudes on induced abortion and family planning among Sri Lankan women seeking the termination of pregnancy”, it was revealed that the majority used induced abortion as a family planning method and it was also revealed that the presence of a young child in the family was the commonest reason for termination. “According to another research carried out in 2014 on people who go to providers of pregnancy termination, it was revealed that the most common reasons for abortion were pregnancy being too soon after the previous delivery or no more children being desired or the curtailment of opportunity for foreign employment. The researchers stated that the need for abortion of these groups are currently not being met through the reproductive health programmes and that it is important therefore that they be given special attention in the future,” Dinethri et al. added. The majority (137/66%) agreed on the fact that there will be advantages after the legalisation of abortion. Almost three fourth (154/75%) agreed that the maternal mortality rate will be reduced and two third (138/68%) believed that unwanted pregnancies would be reduced, if abortion is legalised. According to D.M. Fergusson, L.J. Horwood and E.M. Ridder’s “Abortion in young women and subsequent mental health”, after the legalisation of abortion, the occurrence of mental illnesses, mental stress and family problems that develop due to unsafe abortions are expected to be reduced. When the opinion on the disadvantages of the legalisation of abortion was considered, 135/65% agreed that there will be disadvantages. More than four fifths (167/81%) agreed that there will be the misuse of the legal abortion and about one third (77/37%) agreed that there will be reduced usage of oral contraceptive methods, if abortion is legalised. “Prostitution, the abuse of females and other forms of sexual crime could also be more prevalent,” Dinethri et al. claimed. However, none of the advantages or disadvantages had a statistically significant association with the socio demographic factors. According to the overall opinion on the legalisation of abortion, almost all (200/97%) agreed with abortion when the mother’s life is in danger and more than three fourth (157/76%) agreed with abortion when the mother’s health is in danger.  The majority (117/57%) agreed with the legalisation of abortion in special medical conditions, especially genetic diseases such as Down’s syndrome, anencephaly, thalassaemia major and haemophilia. In the current study, quite a significant number (60/29%) disagreed to legalise abortion in such genetic conditions. Therefore, Dinethri et al. emphasised that until legalisation, the introduction of family screening for genetic diseases, genetic counselling and promoting contraceptive methods would be useful to reduce the incidence of such genetic disease conditions. Accordingly, in Sri Lanka, up to 2008, the rates of abortions had been, per G. Sedgh, S.K. Henshaw, S. Singh, A. Bankole and J. Drescher’s “Legal abortion worldwide: Incidence and recent trends”, declining with improved access to education regarding family planning and birth control. According to the overall opinion, more than two third (141/68%) agreed with abortion in legal conditions such as rape and incest.  However, almost two third (152/74%) disagreed with abortion in social situations such as contraceptive failure, other family members health being in danger and the family having a low income and a high number of children. “This suggests that there is a strong belief among the participants that these social conditions are preventable by way of medical strategies. Further, this disagreement on social conditions had a significant association with the participants’ lack of experience and having less postgraduate qualifications. When contraceptive failure or family health being in danger presented as the condition, the disagreement of doctors with less than 10 years of experience was statistically significant. When the family having a low income and a higher number of children presented as the condition, the disagreement of non-postgraduate doctors was statistically significant,” Dinethri et al. elaborated. Finally, more than two third (143/69%) agreed in legalising abortion for more conditions other than the mother’s life being in danger. In conclusion, it is reiterated that the majority of the participant doctors agreed for the legalisation of abortion for more medical and legal circumstances in addition to when the mother’s life is in danger. The majority however disagreed with abortion in social situations. However, the level of experience and further postgraduate education have significantly reduced the disagreement on social conditions. A nearly equal number of doctors responded that there will be both advantages and disadvantages after the legalisation of abortion in Sri Lanka.


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