When at 19 Mehnaz became pregnant for the fifth time, she panicked. She already had four daughters, and her husband was threatening to throw her out if she had another. So she did what millions of Pakistani women do every year: She had an abortion.
Like many of those women, her abortion was partly self-administered. "I kept taking tablets — whatever I laid my hands on," she says. "I lifted heavy things" — like the furniture in her tiny living room. She drank brews of boiled dates — many Pakistanis believe the beverage triggers labor.
Mehnaz says she felt "a terrible pain in my stomach." Her husband took her to a midwife, who told him the baby was dead. "She gave me injections and it came out," Mehnaz says.
That was eight years ago. Since then she has had two more abortions, each time because she feared the baby would be a daughter.
Mehnaz, whose last name is being shielded to protect her identity, is one of millions of Pakistani women who have abortions each year. The deeply conservative Muslim country is estimated to have one of the highest rates of abortion in the world, based on a 2012 study by the New York-based Population Council, a nonprofit that advocates family planning. The rate that year was 50 abortions for every 1,000 women aged 15 to 44 — roughly four times higher than in the U.S.
The circumstances include a pregnancy that is dangerous to a woman's health — or if there is a "need" for abortion, according to Zeba Sathar, the Pakistan director of Population Council, and Xaher Gul, a Karachi-based public health policy expert and lecturer who advises nonprofits. But what constitutes a "need" is not defined, they say.
What's more, hospitals generally refuse to perform an abortion because most doctors believe it is illegal, Sathar and Gul say. Even when doctors know abortion is allowed in certain circumstances, they cite their own cultural beliefs to not undertake abortions except in urgent cases — for example, if a woman walks in with "an incomplete abortion," Gul says.
That has left Pakistani women at the mercy of back-alley abortion providers.
Some of these women, like Mehnaz, will abort a fetus if they fear they are carrying a female child, who can be seen as an economic burden. But that's not the only reason.
Pakistani women largely seek abortions because they either don't know about contraception or cannot access reliable contraception — or they've stopped using contraception after suffering complications, Sathar says. According to her research, most of the women who seek abortions are married, poor and already have children. Only 30 percent of fertile-age women use modern contraceptives, according to a 2017 U.N. report.
"We found to our surprise that most of the women had more than three children, maybe as many as five," Sathar says. "They were almost all — 90 to 95 percent — married. They were older, so they tended to be poorer, less educated."
Pakistan's high abortion and low contraception rates reflect a family planning policy in shambles, says Abdul Ghaffar Khan, director general of Pakistan's population program wing. His office is meant to set the national family planning agenda, but Khan described the situation as "a bureaucratic mess."
Family planning used to be the job of the federal government, but approval for a national policy languished for years.
In 2011, national authorities passed the matter to provincial governments. But at the provincial level, family planning is not part of the health ministry's portfolio. It is part of a different office and has long been neglected and underfunded, Khan says.
That means women aren't advised about contraception or supplied contraceptives when they are most amenable: after childbirth, receiving postnatal care or immunizing their babies, says Sathar of the Population Council. She described it as one of the chief "structural flaws of how we provide family planning."
The issues with family planning are partly why Pakistan has one of the world's fastest population growth rates, says demography expert Mehtab Karim, vice chancellor at Malir University of Science and Technology in Pakistan. That population boom has strained Pakistan's land and water resources, crowded its schools, outstripped development plans and may lead to more instability in this nuclear-armed state. "It has a tremendous impact," Karim says.
But changes may be coming. On July 4, Pakistan's Supreme Court demanded hearings into the country's family planning failures. A national policy may be put into action in the coming months, Khan says.
All this is too late for Mehnaz, who was married at 13 to her cousin in their tiny village and had four daughters in quick succession and seven children in all — six girls, one son. And three abortions. She is illiterate and said she didn't know anything about sex or contraception early in her marriage.
In a group interview with NPR, about a dozen midwives who also provide abortions said they would only help a woman who already appeared to be miscarrying — like Mehnaz, who induced her own abortion before seeking help.
"I don't help with murder," says Mumtaz Begum, a 60-year-old who lives in a slum in the port city of Karachi. She has no medical qualifications but says a midwife taught her how to induce abortions decades ago, using medications freely available in Pakistan.
On a recent day, Begum showed NPR those pills and injections. They were clustered on a dusty table alongside religious texts and a bag of onions in a dank room with peeling paint. The gurney where she treated women was littered with clothing. "I wipe it down before women come in," she says.
Because many providers aren't properly qualified, researchers estimate about a third of all women who undertake abortions in Pakistan suffer complications, ranging from heavy bleeding to a perforated uterus and deadly infections.
Health workers do reach out to women to provide information about family planning. Some 130,000 women are employed by provincial health ministries to do house visits across the country, teaching about birth control.
But Gul says health workers are poorly trained and in short supply. Budgetary shortages, supply problems and corruption mean they often don't have contraceptives, or distribute expired contraceptives — and that there's little follow-up on how to use them.
Mehnaz was paid a visit by two such workers. She says they gave her an injection meant to prevent conception for three months. She became pregnant again anyway. As before, she tried taking pills to induce an abortion but says they made her sick so she stopped taking them.
Three years ago she had her seventh child, a girl. She then tried taking the pill, offered by the visiting health workers.
She says it made her dizzy and she stopped taking it.
She again became pregnant but miscarried — and pleaded with doctors to sterilize her.
She says they told her she had to wait until she was 40 — or get a permission slip from her husband. He refused: "He says he can't sign this, it's a sin."
She says he also refuses to use condoms or to stop having sex with her.
If she has another girl, her husband may well abandon her. If she tries to induce another abortion, her health could deteriorate.
"I am stuck," she says.
With additional reporting by Saher Baloch in Karachi, Pakistan
STEVE INSKEEP, HOST:
This next story takes us to Pakistan, a deeply conservative Muslim country where doctors routinely refuse to undertake abortions. But it is estimated to have one of the highest rates of abortions in the world - 50 abortions for every 1,000 women. That is more than three times higher than the rate in the United States. A warning - this story may be disturbing for some listeners. NPR's Diaa Hadid reports from Abbottabad.
DIAA HADID, BYLINE: When Mehnaz was 19, she fell pregnant for the fifth time. She already had four daughters. Her husband was threatening to throw her out if she had another girl.
MEHNAZ: (Through translator) When I learned about the pregnancy, my heart sank in fear.
HADID: She knew a midwife who undertook abortions, but only to end pregnancies that were already troubled. So she tried to sabotage her own.
MEHNAZ: (Through translator) I kept taking tablets, whatever I laid my hands on. I lifted heavy things.
HADID: She points to the heavy furniture in her tiny living room - like that, she says. She drank brews of boiled dates. Many Pakistanis believe it triggers labor.
MEHNAZ: (Through translator) Then there was a terrible pain in my stomach. My husband took me to the midwife. She told him the baby was dead. She gave me injections, and it came out.
HADID: That was her first abortion. Mehnaz is now 27. She's got six daughters and one son. She's also had three abortions. She tried to have a fourth by taking pills, but the attempt failed. In Pakistan, many women are pressured to abort fetuses they fear are female because they face rejection if they have too many daughters. They are seen as an economic burden. But that's not the only reason why they're having so many abortions.
XAHER GUL: For the most part, women don't have access.
HADID: This is Xaher Gul. He's a public health expert and adviser on family planning policy. He says women can't get contraception.
GUL: The system is, I would say, disconnected. There are no service providers. If there are service providers, they're not trained. If they are trained, they don't have access to commodities. If they have commodities, they are not good at counseling women. If they are good at counseling women, there is bad follow-up and bad management of side effects.
HADID: Consider Mehnaz's experience. She's illiterate and didn't know about contraception, but she gave birth seven times in a hospital and clearly said she didn't want to have any more children. But nobody there educated her about her options. Worse - after she had her last child, she begged doctors to sterilize her, and they refused.
MEHNAZ: (Through translator) The doctors said I had to get a permission letter signed by my husband, but he won't sign. He says it's a sin.
HADID: Gul, the public health expert, says this is why Pakistan has a thriving underground abortion industry. But the thing is abortion is acceptable in Islam, and it's legal in Pakistan if a woman's health is in danger or if there's a need for it. That need isn't defined, so there's lots of wiggle room. But culturally, it's not OK, so most hospitals will only do them in urgent cases.
GUL: Because they refuse to perform the service, medical doctors themselves for the most part have pushed women in need of therapeutic abortions into back alleys.
(SOUNDBITE OF BABIES CRYING)
HADID: We went to a back alley in a slum to meet an abortion provider, Mumtaz Begum. She's about 60. She charges between $25 and $70 for an abortion.
MUMTAZ BEGUM: (Through translator) I'm not educated, but I have a lot of experience.
HADID: Begum's clinic is dank, and the pink paint peels off the walls. There's a dusty table piled with medicines, a bag of onions and a stack of Qurans, the Muslim holy book. Begum also leads pilgrimages to holy sites. And she says, because she's devout, she'll only do abortions for women whose pregnancies are already in trouble. Otherwise, she believes it's murder.
BEGUM: (Through translator) I don't help with murder, but if there is a necessity - for instance, if the woman is bleeding - then I clean out her womb.
HADID: What's clear in the interview with Begum and other abortion providers is that most of them expect women to look desperate. And like Mehnaz, women will hurt themselves to get help. That, combined with the lack of hygiene and training, makes abortions in Pakistan dangerous and sometimes deadly. This is Gul.
GUL: Nearly about a fifth of the women who die because of pregnancy-related complications die because of unsafe or less-safe abortions.
HADID: That's thousands of women every year.
(SOUNDBITE OF CALL TO PRAYER OVER LOUDSPEAKERS)
HADID: Gul directs us to a clinic run by an organization that offers contraception and safe, legal abortions. We aren't naming them out of concerns they'll be harassed. The Muslim call to prayer echoes outside.
(SOUNDBITE OF CALL TO PRAYER OVER LOUDSPEAKERS)
HADID: Inside, we meet Asma. She only gives us her first name. She's 32, a conservative Muslim. And she wears a long black robe and covers her hair and face with a black veil. She's got four kids, and she's waiting for an ultrasound to see if she's pregnant again.
ASMA: (Through translator) When I'm pregnant, I can't walk. I can't stand. I vomit all the time. My body swells up.
HADID: If she finds out she's pregnant, she'll get an abortion here. She feels there's no conflict between her faith and her need to terminate her pregnancy.
ASMA: (Through translator) I have to look after my life as well. I have other children to take care of.
HADID: Mehnaz, who we meet at the start of the story who's already had three abortions, can only dream of that kind of service. She lives in fear of falling pregnant again. Her husband won't use contraception and refuses to stop having sex with her. He also constantly threatens to throw her out if she has another daughter.
MEHNAZ: (Foreign language spoken).
HADID: "I'm stuck," she says. "This society doesn't let women live."
Diaa Hadid, NPR News, Abbottabad.
(SOUNDBITE OF OLDTWIG'S "DUNES") Transcript provided by NPR, Copyright NPR.