Health Messenger Article – Post Abortion Care               September 2002

Title: Post Abortion Care: Who Cares?

Suzanne Belton, Midwife Ph D Candidate

Melbourne University, Australia

E-mail: suzannebelton@hotmail.com

 

A version of this appeared in the following magazine that is produced for health workers on the Thai-Burma border and India.

 

Belton, S. (2003). Unsafe Abortion and its Prevention: Who cares? Health Messenger. March: 46-53.

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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.

 

Economic problems and lack of rights for working women

Ma Win Kyaw is 32 years old, Buddhist and comes from Karen State.  She has lived in Thailand for six months and is married. She has three children in Burma that are being looked after by her mother and she sends money home when she can.  She works in a low paying job in a factory making clothes.  She works long hours and doesn’t get enough sleep.  Her husband works in the factory as well and he can earn about 100B per day.  She uses Kathy Pan[1] every month to make sure her period comes but she hasn’t seen any blood for two months now.  She told her husband and a couple of friends that she thinks she is pregnant and her husband said she should stop the pregnancy because they need to save money.  She asks her friend what to do and they decide to go to the market and find some medicine.  At the market they buy Nequezee for 12B and the woman behind the stall says that if that doesn’t work she can help her fix it.  One week later after trying Nequezee and drinking ginger and sugar cane water she feels sick with worry as her period has not come.  The Thai boss came and quietly threatened her.  He had found out that she was pregnant and he told her that she and her husband would lose their jobs if she didn’t get rid of it.  He said he didn’t want any pregnant women in his factory.  What should she do?  She could travel home and have the baby in Burma but one more mouth to feed would push them into deeper poverty.  The situation in Burma is bad and the price of food and essentials rises every week.  No-one taught her or her husband about family planning and she only went to school for three years but she can read.  She knows that it is possible to stop the pregnancy but she doesn’t know where to go to get help.

 

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 Thailand. Her family relies on her income.  It is a sin in her religion but she hopes Budda will understand her desperation and she will do something very good afterwards to improve the karmic problem.  Also she thinks it is just a little piece of blood at this stage and not essentially human yet so not such a big sin.  She finds the house near the market, the old woman is friendly and tells her that she will use a ‘medicine stick’ (se yoh) and it won’t hurt.  She hardly feels anything as the woman puts two 10cm bent sticks from a tree inside her cervix, just a little cramping like a period.  She pays the woman 500B and goes home feeling relieved.

 

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.  

 

 

Common problem for married women

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 Thailand and Burma to receive help.

 

 

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.

 

Burma’s situation is quite different to Thailand.  Burma has been strongly pro-natalist and only began a limited child spacing programme after a visit and some financial support by United Nations Family Planning in 1995 (United Nations Family Planning Association 1999).  The United Nations assessment showed "Reports from previous studies indicate that approximately 50 percent of maternal deaths are due to abortion related complications (Tun Yee 1990, Than Than Yin 1992, Central Women's Hospital 1997)." [UNFPA 1999: 22] 

An article by Dr Ba Thike (Ba-Thike 1997) inside Burma showed that the morbidity and mortality due to unsafe abortions was very high and complications of abortions has appeared in the top ten list of public health problems by the military government for several years now.  This is a strong indicator of unmet need for contraceptive services. 

 

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 Thailand and Burma. 

 

Providing safe, legal abortion services is one way that some countries decide to prevent the serious illness and loss of life of women.  Singapore provides abortion on request, Bangladesh provides early abortions for women and Malaysia’s abortion laws are also quite liberal.  In Australia abortion is provided up to 12 weeks by the government health sector at minimal cost if the woman and two doctors agree that the pregnancy would be negative to her mental or social well-being.

 

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 Thailand.  Many Burmese women who live outside of the UNHCR camps report living in unstable conditions with very few human rights or access to health services.  Their decision to end their pregnancy is often economically motivated and they risk their fertility, future health and sometimes their life in procuring the end of the pregnancy. Studies have found that basic knowledge of sexual health issues such as fertility and reproduction are extremely low (Caouette, Kritaya Archanvanitkul et al. 2000; Kritaya Archavanitikul 2000).  While high levels of knowledge does not always equal good, health behaviour some culturally appropriate public health reproductive health education programme in the Karen and Burman languages would be beneficial.  Health workers can find this ‘self-inflicted’ type of illness difficult to understand but set in the context of broader social, political and economic lack of rights and abuses it becomes easier to care.  Training and discussions sessions for health workers who care for women with the problems related to abortion should be implemented and supported by managers.

 



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 Thailand that I will follow-up.