A version of this appeared in the following
magazine that is produced for health workers on the Thai-Burma border and
Belton, S. (2003).
Unsafe Abortion and its Prevention: Who cares? Health
Messenger. March: 46-53.
__________________________________________________________
This article is intended to give health workers an introduction into the individual implications of pregnancy loss as well as local issues on the Thai-Burma border and broader South-east Asian regional issues. I want to focus on the gender and social features rather than pure biomedical information, although this is of course highly important but is covered in other parts of this magazine. I will talk about some women’s stories that were collected in 2002 to outline typical cases, the reasons why the woman chose to end the pregnancy and impact on women’s lives. I will also present some findings from a medical records review conducted with the Mae Tao Clinic and discuss some findings from research in the international arena. So should we care about post abortion care? I hope to show that we should, as not only can it be a life threatening event for the woman but it reflects certain aspects about the communities we live in, social conditions, legal and religious norms, how we value human rights and the status of women.
During 2002 I spent time
looking back in past medical records of women who had been admitted or who had
visited the Mae Tao Clinic and/ or Thai health services for obstetric emergency
reasons related to the ending of a pregnancy before seven months
gestation. I also interviewed more than
20 Burmese traditional and modern health workers and 43 Burmese women and some
of their husbands. I have not finished
my study yet but have enough information to begin telling you about what is
happening. Let me start by telling you a
story. This story is not about one woman
but is a compilation of many women’s stories.
Ma Win Kyaw is 32 years old,
Buddhist and comes from
Her friend takes her to the
market again and the woman tells them where to find the ‘old woman’ (aporgee) who
knows these things. Ma Win Kyaw feels
frightened but determined not to spoil her family’s chance to earn some money
in
A little over a week later
she is spotting and cramping and feels happy that it will soon be over. She continues to work in the factory until
the pain and blood loss increase so much she cannot stand any more without
fainting. She has chills and fever and
feels like vomiting. She has a terrible
headache and pain worse than when she gave birth. Her husband takes her to the clinic on the
back of his bike. It is late in the
evening when the health worker examines Ma Win Kyaw and diagnoses an induced
inevitable septic abortion. The health
worker asks her why she risked so much, her fertility and her life? She feels so
guilty she doesn’t say anything.
This story is one of similar
stories that I heard. Who is
responsible? The woman, her husband, her
friend, the ‘old woman’, the factory owner, the Thai government for not
monitoring migrant workers labour laws, the Burmese dictatorship due to its
mishandling of the economy, the international community that wants cheap
consumable products regardless of how or where they are produced? Post abortion care is not only a medical
problem. It often reflects social
inequalities and human rights abuses on a broad scale.
In 2001 at the Mae Tao
Clinic 457 women attended for complications for post abortion care and 563
women attended for birth services. It
must be remembered that many women who come to Mae Tao Clinic for antenatal
care choose to give birth at home so the delivery figure is not a
denominator. About three quarters of
these 457 women had natural abortions or miscarriages and one quarter had tried
to end their pregnancy themself.
Abortion is a medical term that simply means the end of a pregnancy and
it should be qualified as either spontaneous or induced to give a complete
diagnosis. The majority of women who
attended the Clinic required in-patient treatment as they were so unwell (Out
Patient Department 197 women - In Patient Department 260 women). During 2001, thirty-one women were referred
to the local Thai hospital and one woman died[2]. The cost of caring for only the thirty-one
women in the Thai hospital for 11 days was 71,432 Baht. This is an average of 2,300 Baht per woman
hospitalised.
Table 1. The increasing numbers of
deliveries and post abortion care cases at Mae Tao Clinic
|
Year |
Number
of deliveries |
Number
of post abortion cases |
|
2001 |
563 |
457 |
|
2000 |
414 |
213 |
|
1999 |
291 |
277 |
I decided to look at the medical records held by the Mae Tao Clinic of the 197 women who attended the outpatient department for reasons related to pregnancy loss, miscarriage or abortion. I collected several items from the medical records such as age, marital status, the numbers of pregnancies, births and living children. I also looked at treatment, numbers of visits and family planning. This is a brief summary of the findings.
q Abortions or miscarriages form a large part of the work performed by the health workers in Reproductive Health Out Patient and In Patient Departments.
q On average 16 women per month come to MT Clinic OPD for help with an abortion problem.
q Ten percent of women complaining of an abortion problem are young, 20 years or less.
q Seventeen percent of women complaining of an abortion problem are 35 years or more.
q Over a third of women experiencing an abortion have no children.
q Half have never experienced an abortion before.
q Just under half have had five or more pregnancies, which can be considered at health risk.
q At least one quarter of abortions are thought to be self-induced.
q Women use many methods to end their pregnancy including Western and Burmese medicine, massages and insertion of objects into the sex organs.
q Traditional midwives offer abortion services to women.
q One woman died due to her abortion and over thirty were sent to hospital.
q Most pregnancies end in the early stages of pregnancy.
q Women require a lot of medical help in the form of advice, medicine and blood transfusions.
q Women have to make many trips to get their health care.
q Over half of women do not receive contraception, even when they fall into risk groups.
q Most women are married.
q Social information is not often recorded in the medical records.
q
Most women come from the local
area but some travel from rural areas in
So who
cares about post abortion care?
The Mae Tao Clinic health workers are currently improving the care they provide to women with abortion complications with the help of the Women’s Commission for Refugee Women and Children. The next question for Thai and Burmese health service providers in the area would be how to prevent the complications of abortion that can cause sickness, missed income, infertility, feelings of guilt, or death. A community education promotion campaign about contraception and sexual health for men and women would be one way but there are many barriers and difficulties. Migrant workers are mobile populations that have little free time, employers often fail to understand the health needs of their staff, the illegal status of some of the people make contacting them difficult and community attitudes can prevent discussion as well as the prohibitive cost of providing education and services.
Another way is to provide
safe and clean abortions for women who do not wish to continue their unwanted
pregnancy. In this region of the world
access to contraception and safe, clean abortion services is variable. Thailand has experienced several decades of
public awareness campaigns regarding family size and contraception which has
led to the idea that two children per family is enough and also the
acceptability of many forms of modern contraception. Thai people also have accessible village and
town level health services at a reasonable cost. Thai maternal and infant mortality rates are
low and sanitation and the general well being of people is quite good. Although access to safe abortion is not easy
and a Thai woman needs to prove that her life is in danger or that she has been
raped in order to legally end her pregnancy.
Many Thai women do opt to have an illegal abortion and about 19 women
die each year (Whittaker 2000). Although Thai people have generally accepted the
idea of using many modern methods of contraception, I found in my study that
Burmese women who had been referred to the local Thai hospital for post
abortion care were not given contraceptive options. A few Burmese women were offered tubal
ligation but no other modern method was discussed with them and neither was
reading material provided. Tubal
ligation is not a method of choice for women who have not yet completed their
family but having said this Burmese women in my study reported that they liked
to be able to get a tubal ligation at a reasonable price if they wanted
one. Also Thai and Burmese notions of
the ideal family size are different and this cultural confusion does not
facilitate quality care for Burmese women.
As most women require some form of short term or long term contraception
after either a spontaneous or induced abortion, it is surprising that women are
not offered easier access to a reliable method of fertility control. The Thai doctor in charge of this area is now
reconsidering his post abortion care policy.
An article by
Dr Ba Thike (Ba-Thike
1997) inside
Legal
abortion is restricted to the criteria to save the mother’s life only. The living conditions and development of
health, education resources and infrastructure are obviously very different
between
Providing
safe, legal abortion services is one way that some countries decide to prevent
the serious illness and loss of life of women.
In addition Burmese women use traditional or herbal methods with unknown efficacy to regulate their periods and provide some contraception. A quick walk in the local market offers an array of quack potions and out of date medicines that women are offered by market vendors. I asked a group of traditional birth attendant trainers how many methods of contraception they were aware of. They reported 20 different non-modern methods and five modern methods. Non- modern methods practices by mainly Karen people included eating special types of roots, leaves or vegetables, twisting or lifting the womb, coughing out semen after sex, putting a thread around the woman’s waist, washing after sex, massages, breastfeeding and having rectal sexual intercourse. Interestingly they included abortion as a non-modern method of fertility control. Another significant difference is the ideal family size. In my own study I asked Karen health workers what their idea of the right number of children in a family was and most reported that three to four children per couple would be perfect.
Providing
reproductive health services
In this
article I have talked about the commonest reason for an unwanted pregnancy for
Burmese women living in
Ba-Thike, K. (1997). “Abortion: A Public Health Problem in
Myanmar.” Reproductive Health Matters 9(May): 94-100.
Caouette, T., Kritaya Archanvanitkul, et al.
(2000). Sexuality, Reproductive Health and Violence: Experiences of Migrants
from Burma in Thailand., Mahidol
University.
Kritaya Archavanitikul, P. G., Saowaphak Suksinchai (2000). Displaced Persons in Thailand: A Focus
on Health Issues, Institute for Population and Social Research, Mahidol University.
United
Nations Family Planning Association (1999). Reproductive Health Needs
Assessment in Myanmar, United Nations Family Planning Association.
Whittaker, A. (2000). Intimate Knowledge Women and their health in North-East Thailand,
Allen and Unwin.
[1] Kathy Pan is a herbal medicine sold in shops and markets for about 30B that is widely used to ‘regulate periods’. Many Burmese women use it as a defacto contraceptive / abortifacient.
[2] I have also an unconfirmed report of another Burmese woman dying of
post abortion complications in a rural hospital in