Geisha Kow­lessar

At age 17, Mia had her first abor­tion.Un­wed and job­less and the el­dest of six chil­dren, Mia was en­cour­aged by her fa­ther to abort her un­born ba­by."It was an easy but very painful way out," she re­called non­cha­lant­ly.Now mar­ried with three chil­dren years lat­er, Mia has en­dured a to­tal of sev­en abor­tions be­fore and af­ter her mar­riage.The rea­son, she said, was sim­ply one of con­tra­cep­tion - the pill made her ill and her hus­band did not be­lieve in con­dom use.

But the last pro­ce­dure near­ly cost Mia her life."The abor­tion was in­com­plete and I end­ed up in the hos­pi­tal. I re­mem­ber ly­ing on the hos­pi­tal bed and be­ing in and out of con­scious­ness."I saw the oth­er women on the ward who had come for the same thing leav­ing. I could not get off the bed."I promised God this would be my last abor­tion and I asked him to al­low me to live to take care of my chil­dren," Mia said.Mia's sto­ry rep­re­sents the plight of thou­sands of women in Trinidad and To­ba­go who ei­ther die or nar­row­ly es­cape death due to sep­tic abor­tions.

Ac­cord­ing to sta­tis­tics pro­vid­ed by the group, AS­PIRE, which is lob­by­ing for bet­ter stan­dards of health care and more rights for women, be­tween 3,000 to 4,000 women are ad­mit­ted to pub­lic hos­pi­tals year­ly due to com­pli­ca­tions from un­safe abor­tions.These women con­se­quent­ly have to un­der­go a di­la­tion and curet­tage (DNC).That, AS­PIRE said, was cost­ing tax­pay­ers more than $12 mil­lion a year.Health Min­is­ter Dr Fuad Khan said re­cent fig­ures com­plied by his min­istry had shown an in­crease in sep­tic and ma­ter­nal mor­tal­i­ty rates, with be­tween 13 to 15 per cent of these deaths due to sep­tic abor­tions.

De­scrib­ing the trend as very dis­turb­ing and a cause for grave con­cern, Khan said too of­ten women were plac­ing their lives in the hands of un­scrupu­lous "back­yard abor­tion­ists."He added: "A high per­cent­age of the ma­ter­nal mor­tal­i­ty rate oc­curs as a re­sult of sep­tic abor­tions in the wrong hands. This is peo­ple go­ing to 'out­side abor­tion­ists.'" Ques­tioned what could Gov­ern­ment im­ple­ment to pre­vent women from un­der­go­ing un­safe abor­tions, there­by re­duc­ing the ma­ter­nal mor­tal­i­ty rate, Khan said seek­ing an abor­tion was pri­mar­i­ly a moral de­ci­sion.

He added: "The is­sue of sep­tic abor­tions, how­ev­er, re­mains a grave con­cern to the Health Min­istry and it is an is­sue we are ag­gres­sive­ly look­ing at."But is it re­al­ly a moral choice. We have to come to an un­der­stand­ing and we need to re­duce the ma­ter­nal mor­tal­i­ty fig­ures be­cause too many women are con­tin­u­ing to lose their lives due to sep­tic abor­tions."

Greater need to ed­u­cate-OBG­YN

Lead­ing lo­cal spe­cial­ist in the field of Ob­stet­rics and Gy­nae­col­o­gy (OBG­YN) Dr Sherene Kalloo agreed there was ur­gent need to re­duce the ma­ter­nal mor­tal­i­ty rate."Sep­tic abor­tions are a prob­lem. It has been a prob­lem and will con­tin­ue to be a prob­lem un­less we can iden­ti­fy how we can pre­vent it."We have been able to keep the ma­ter­nal mor­tal­i­ty rate at a lev­el that is still not ac­cept­able. It is a high fig­ure but I would not say it is on the rise. We have had an in­flux of deaths with­in the last six months," Kalloo said.She al­so not­ed there was an in­crease in 'med­ical abor­tions'which al­so re­sult­ed in ma­ter­nal deaths.

"What we're see­ing more of are med­ical abor­tions, mean­ing that peo­ple are us­ing tablets and in­duc­ing mis­car­riages and be­cause of that they are not able to iden­ti­fy when they have a com­pli­ca­tion," Kalloo ex­plained.She said as a re­sult, com­pli­ca­tions, in­clud­ing haem­or­rhag­ing, oc­curred."Ear­ly com­pli­ca­tions can be haem­or­rhage or sep­sis with sep­sis be­ing a big fac­tor and haem­or­rhage be­ing a big­ger prob­lem but when added with oth­er caus­es, haem­or­rhage be­comes the first cause of ma­ter­nal deaths," Kalloo said.

Ac­cord­ing to Kalloo, cy­totec, a drug used to treat stom­ach prob­lems which is eas­i­ly avail­able over the counter, is used to per­form "med­ical abor­tions."In her 30 years of prac­tice, Kalloo said she had wit­nessed an in­crease in women be­ing treat­ed for com­pli­ca­tions aris­ing from sep­tic abor­tions."I have been see­ing more pa­tients as­so­ci­at­ed with com­pli­ca­tions of sep­tic abor­tions but thank­ful­ly they have ar­rived at the of­fice in a time­ly man­ner where they are able to get treat­ment for in­fec­tion and avoid mor­tal­i­ty," Kalloo added.

Apart from ma­ter­nal mor­tal­i­ty, the prob­lem of ma­ter­nal mor­bid­i­ty al­so arose with sep­tic abor­tions."There is def­i­nite­ly an in­crease in ma­ter­nal mor­bid­i­ty and that's what we need to ad­dress," Kalloo urged.She said pre­ven­tion be­gins with fam­i­ly plan­ning and aware­ness and if preg­nan­cies were pre­vent­ed that would al­so lead to a pre­ven­tion in un­want­ed preg­nan­cies and ul­ti­mate­ly re­duce the ma­ter­nal mor­tal­i­ty rate."We need to make fam­i­ly plan­ning tech­niques more eas­i­ly ac­ces­si­ble to our pop­u­la­tion so the whole as­pect of ed­u­ca­tion, the me­dia in­flu­enc­ing that, the Gov­ern­ment step­ping in and the Gov­ern­ment in­tro­duc­ing new ways and means of get­ting peo­ple to come to the health cen­tres and mak­ing sure that it's a free en­ti­ty," Kalloo added.

She said women most af­flict­ed with com­pli­ca­tions from sep­tic abor­tions be­longed to the low­er so­cio-eco­nom­ic brack­et."The peo­ple who do have the mon­ey are the peo­ple who would go to the pri­vate doc­tors, the peo­ple who would af­ford to get ed­u­ca­tion and the peo­ple who would use what they have to pre­vent a preg­nan­cy,"she added.

Guide­lines need­ed­for ter­mi­na­tion

Se­nior board mem­ber of AS­PIRE Dr Var­ma Deyals­ingh said the or­gan­i­sa­tion had been lob­by­ing the Health Min­istry to im­ple­ment guide­lines for health care pro­fes­sion­als re­gard­ing the ter­mi­na­tion of preg­nan­cies.He said: "It's re­al­ly pa­thet­ic that women would have to un­der­go such prob­lems in this day and age like sep­tic abor­tions and we could have a health care sys­tem could eas­i­ly al­le­vi­ate this prob­lem."Sep­tic abor­tions im­pact on the hos­pi­tals hav­ing to spend mon­ey to keep pa­tients and at the end of the day it's al­so a pub­lic health is­sue.

Sep­tic abor­tions do im­pinge on the pub­lic's purse," Dr Deyals­ingh said.He said in cas­es of rape, foe­tus de­for­mi­ty and where a moth­er's life was at risk, guide­lines should be set to de­ter­mine preg­nan­cy ter­mi­na­tion.Deyals­ingh said the group had been lob­by­ing since 2000 and a sur­vey they con­duct­ed re­vealed that 69 per cent of the pop­u­la­tion was in favour of change of the law and that abor­tion should be a choice for woman.

Last Oc­to­ber 23, AS­PIRE held a sym­po­sium at the Hy­att Re­gency Ho­tel, Port-of-Spain, themed "Safe Moth­er­hood: Best Prac­tices for Re­duc­ing Ma­ter­nal Mor­tal­i­ty."Ac­knowl­edg­ing that ma­ter­nal deaths are of­ten as­so­ci­at­ed with sub­stan­dard care and fac­tors that could be avoid­ed, AS­PIRE al­so not­ed that sev­er­al health care work­ers were un­able to recog­nise and man­age med­ical con­di­tions or po­ten­tial emer­gen­cies that were not part of their rel­e­vant med­ical ex­per­tise."The sym­po­sium was birthed as a re­sult of the large num­ber of ma­ter­nal deaths in Trinidad in 2011 and the con­tin­u­ing high lev­els of ma­ter­nal mor­tal­i­ty in Trinidad in 2011 and con­tin­u­ing high lev­els of ma­ter­nal mor­tal­i­ty glob­al­ly." it was stat­ed.

D and C is a pro­ce­dure to scrape and col­lect the tis­sue (en­dometri­um) from in­side the uterus.

• Di­la­tion ("D") is a widen­ing of the cervix to al­low in­stru­ments in­to the uterus;

• Curet­tage ("C") is the scrap­ing of the walls of the uterus.

De­scrip­tion

D and C, al­so called uter­ine scrap­ing, is per­formed in the hos­pi­tal or in a clin­ic un­der gen­er­al or lo­cal anaes­the­sia.An in­stru­ment, called a specu­lum, is in­sert­ed in­to the vagi­na. This holds open the vagi­nal canal. Numb­ing med­i­cine may be ap­plied to the open­ing to the uterus (cervix).

The cer­vi­cal canal is widened, us­ing a met­al rod, and a curette (a met­al loop on the end of a long, thin han­dle) is passed through the open­ing in­to the uterus cav­i­ty.The doc­tor gen­tly scrapes the in­ner lay­er of tis­sue, called the en­dometri­um. The tis­sue is col­lect­ed for ex­am­i­na­tion.

Why the Pro­ce­dure is Per­formedThis pro­ce­dure may be done to:

• Di­ag­nose con­di­tions, such as uter­ine can­cer;

• re­move tis­sue af­ter a mis­car­riage;

• treat heavy men­stru­al bleed­ing or ir­reg­u­lar pe­ri­ods (See: Bleed­ing be­tween pe­ri­ods); and

• per­form a ther­a­peu­tic or elec­tive abor­tion

Risks re­lat­ed to D and C in­clude:

• Punc­ture of the uterus;

• Scar­ring of the uter­ine lin­ing (Ash­er­man Syn­drome, may lead to in­fer­til­i­ty lat­er); and

• tear of the cervix.

Strate­gies by Health Min­istry to im­prove ma­ter­nal mor­tal­i­ty

• A re­vised ma­ter­nal and child health pol­i­cy;

• de­vel­op­ment of stan­dard op­er­at­ing pro­ce­dures for ob­stet­rics and mid­wifery;

• strength­ened ante-na­tal care ser­vices through the pur­chase of ad­di­tion­al equip­ment, in par­tic­u­lar foetal mon­i­tors, re­fur­bish­ment of pri­ma­ry heath care ser­vices and in­ter­nal train­ing of staff;

• up­grade of cur­rent pro­grammes, such as the fam­i­ly plan­ning pop­u­la­tion pro­gramme and the ex­pand­ed pro­gramme on im­mu­ni­sa­tion; and

• de­vel­op­ment of strate­gies to at­tract ad­di­tion­al health care pro­fes­sion­als.

Law Re­form Lit­i­ga­tion

AS­PIRE has lob­bied for abor­tion law re­form since 2000 on the ground that the crim­i­nal law has cre­at­ed a pub­lic health cri­sis.In 2002, the or­gan­i­sa­tion is­sued a for­mal pe­ti­tion to Gov­ern­ment ask­ing for clar­i­fi­ca­tion of ex­ist­ing law, in­quiry in­to the law's im­pact on women's health and pub­lic di­a­logue.In 2006 the Colom­bian Con­sti­tu­tion­al Court ruled that abor­tion must be per­mit­ted when a preg­nan­cy threat­ened a woman's life of health, in cas­es of rape or in­cest and in cas­es where the foe­tus has mal­for­ma­tions in­com­pat­i­ble with life out­side the womb.

Ear­li­er that year, in a land­mark set­tle­ment, the Mex­i­can Gov­ern­ment agreed to is­sue a de­cree reg­u­lat­ing guide­lines for ac­cess to abor­tion for rape vic­tims.In 2005, the Unit­ed Na­tions Hu­man Rights Com­mit­tee held the Pe­ru­vian Gov­ern­ment ac­count­able for fail­ing to en­sure ac­cess to le­gal abor­tion in a case where the foe­tus had a fa­tal ab­nor­mal­i­ty.