Abortion – Is it always “bad”?
View(s):This article is intended to create awareness in society of a social issue which seems to have lost focus of the core issue. Clearly the reasons for it not to reach an acceptable solution involve the way the problem is viewed from the platforms of religious beliefs, social implications, cultural reasons etc. But the time has come to give priority to medical implications and social impact without further delay.
Dr. Gihan Abeywardena
The existing abortion law in Sri Lanka allows abortions ONLY when pregnancy and child birth is life threatening to the mother. In April 2012 the Minister for Child Development and Women’s Affairs, Tissa Karalliyadde, suggested reforms to the current law to allow abortions under strict conditions for girls under18 years who have become pregnant due to rape or incest and for mothers carrying babies with severe genetic malformations. Unfortunately this amendment was not implemented as suggested, due to ‘unknown’ reasons.
Here are a few case histories of patients with unwanted pregnancies who were referred to us for psychiatric intervention at Matale Hospital in the recent past.
Case Scenario 1
A 17-year-old schoolgirl from a remote village in Matale district bordering Polonnaruwa was referred by the Obstetrician with depressive features and suicidal ideas when she was 25 weeks pregnant.
She had just passed her GCE Ordinary Level exam and was hoping to enter a Maha Vidyalaya in town as the village school had no Advanced Level classes. The poverty stricken family struggled hard to make ends meet by cultivating a chena in the middle of the thick jungle bordering the Wasgamuwa wildlife park. Their crop was often destroyed by wild elephants. She had a brother aged 22 who was mentally retarded, intermittently aggressive and violent. The father had to stay in the chena at night leaving the family at home.
One day when both parents were harvesting their crop the brother raped her. Her cries were not heard by anyone as there were no houses nearby. She concealed the rape from her mother due to the fear of her parents beating up the brother and chasing him away. Ten weeks later she developed morning sickness, and was taken to the rural hospital where she was found to be pregnant. She was transferred to Matale Hospital where her pregnancy was confirmed by an ultrasound scan and referred for the opinion of termination of pregnancy to several clinicians.
Unfortunately at that time due to the legal restrictions against abortion in Sri Lanka, the clinicians who examined her had been unable to go ahead with the termination of pregnancy. I joined Matale Hospital later on when she was six months pregnant and by that time she was depressed and helpless, but it was too late for any obstetrician to go ahead with an abortion due to the risk to the mother with the advanced pregnancy.
She was started on treatment for Depression with minimal response and later delivered an abnormal baby with deformed hands, very small head and heart valve problems. Her parents found it extremely difficult to face the villagers and had to move to another area. The day prior to moving the brother who probably was under severe pressure from family members and villagers committed suicide.
The baby was on treatment for several weeks in the sick baby unit and was discharged. The grandparents agreed to raise it even with great difficulties.
The mother of the baby was seen once after delivery in the psychiatric clinic, but never came back to us after changing residence. I only hope that she is still alive, but she definitely must be going through a lot of hardships in raising a deformed baby with severe economic hardships and no father. More than anything else she probably is finding it extremely difficult to face the public and the insults of delivering an “illegitimate” child of her own brother.
Case Scenario 2
A 14-year-old schoolgirl from a tea estate in Rattota was referred by the Judicial Medial Officer for a psychiatric opinion with suspected Post Traumatic Stress Disorder. This girl was admitted to the hospital by the Police after her mother had filed a complaint that the girl’s father had repeatedly raped her on several occasions. The father was in remand custody by that time and the teenage girl 12 weeks and 6 days pregnant according to the ultra sound scan done in the hospital.
t was revealed later on by this girl that her father had repeatedly raped her after tying her to the bed under the influence of alcohol. He was unemployed at that time due to ‘disability’ and he had forced his wife into employment as a manual labourer and also demanded money from her for alcohol on a daily basis. There was only a two-year-old sister at home when the mother went to work.
It was revealed later on that her father had forbidden the girl from telling her mother, threatening to kill the mother if she did so. She was a bright student who was among the top three in her class but she started refusing to go to school and was later admitted to the estate hospital with lower abdominal pain and difficulty in passing urine. It was found that she was pregnant. The mother got the information about the rape and pregnancy through the doctor.
Luckily the mother reported this promptly to the Police. The daughter was admitted to Matale hospital for a medico-legal examination. This unfortunate girl was in a ‘hyper-aroused’ state when referred to me, with frequent flashbacks of the traumatic incident of her father raping her and threatening to kill the mother. She point blank refused to go back home and did not wish to ever see her father again. It was later found out that she had been harbouring suicidal ideation with active plans to end her life prior to hospitalisation.
The Consultant Obstetrician was strongly recommended by me to terminate her pregnancy, considering her mental state and the risk to her life if the pregnancy continues. Both the patient and her mother provided written consent for the procedure. The Obstetrician acted promptly by obtaining a second opinion by an independent Obstetrician and referred her on the very next day for a second psychiatric opinion to the Consultant Psychiatrist at Teaching Hospital Peradeniya.
ll the four clinicians involved unequivocally declared that an abortion should be performed in the best interests of the patient to save her life. Her pregnancy was terminated within the same week on medical grounds as she was already over 12 weeks pregnant and we could not wait any longer, and we recommended a change of school and foster care. She was referred to the probation officer attached to the Department of Social Welfare, Probation and Child Protection Services in Matale. The girl refused to change her school and did not want to go to a children’s home, and happily went back home with the mother as the mother decided to separate from the father.
She is back at school and doing well and we see her regularly in the psychiatric clinic. Her medications are being gradually reduced and she continues to undergo counselling. Her father has been sentenced to prison on charges of incest. Can you imagine the emotional turmoil that she would have been in and the agony that she would have gone through if she had her own father’s child growing inside her and had to be a mother at the tender age of 14 years?
In most of the cases the hospital authorities are notified of these unfortunate pregnancies quite late, when the Obstetricians are unable to perform abortions. Due to the law against abortion in Sri Lanka, clinicians find it extremely difficult to get the consent from legal authorities and professional agreement from other clinicians in time even for termination due to medical grounds. By the time all this ‘red tape’ procedures are over, the pregnancy in most cases has advanced beyond the stage of abortion.
We also come across some clinicians who are ever so reluctant to consider termination of pregnancy under any circumstances. We also have come across mothers who have killed their babies soon after delivery and gone to prison for murder or manslaughter, and more commonly pregnant women who risk their lives by going in to “illegal Abortion Centres” all over the country and undergoing criminal abortions.
Case Scenario 3
An 18-year-old pregnant patient was referred to the psychiatry unit following her third suicide attempt. She was from Anuradhapura and had attended a popular school where she had excelled in studies with 9 distinctions at the GCE Ordinary Level Exam, in spite of economic hardships and family problems. There were intense parental conflicts at home, and her father left her mother to raise four young children. The mother could not afford to send this, her eldest daughter to A” Level classes but she was determined to study and subsequently fell in love with a 22-year-old man from Matale who went to Anuradhapura for employment. He had paid all her tuition fees and encouraged her to study.
In the meantime her father returned home one day when the mother was away and chased his daughter away, leaving her no other option but to go to her boy friend, whom she started living with. She was then brought to Matale to his parents, while he continued to work in Anuradhapura. The mother of her partner was closely attached to her son and could not tolerate her presence at home. The sister also advised her not to take contraceptive pills, telling her that these pills will make her infertile in the future. The patient believed this and advised her boy friend to have physical contacts with her only during the ‘safe period’. She subsequently became pregnant and the boyfriend’s mother was furious getting to know about this.
The patient considered her pregnancy as the biggest obstacle to her studies and began to hate the unborn child and tried her best to abort it on her own, without any success. In the meantime the school authorities (she had joined another school in Matale) got to know about her pregnancy and expelled her from school. All her hopes of higher education fell apart and she became increasingly agitated towards her boy friend, assaulted him repeatedly for making her pregnant and tried several times to end her life. Her mother meanwhile learning of the pregnancy suffered a ‘heart attack’. She was admitted to Anuradhapura hospital, but her father adamantly prohibited the girl from visiting her mother. The patient then tried to hang herself and was brought to Matale hospital by her boyfriend.
I will not reveal the outcome of this unwanted pregnancy, and leave you with a sensitive, but important question. If you happened to be this patient’s treating Obstetrician or Psychiatrist at hospital, what decision would you have taken in this situation? Would you allow her to go on with her pregnancy and make her face the consequences or suggest the termination of her pregnancy considering the severe risk to her life due to depression and suicide?
As a Psychiatrist, I would like to commend the statement of the current Minister of Child Development and Women’s Affairs on 14/04/2012 where he boldly stated that “ I must emphasize that this amendment to the law on abortion is not an open licence to abort unborn embryos. We thought of allowing this under strict conditions giving consideration to the well being of the women concerned. Special consideration will be given to women who are raped. It is obvious that they cannot face society and have to undergo severe mental strain throughout their lives”.
It is high time that all of us got together to amend the current outdated law on abortion in Sri Lanka. It is absolutely necessary to pay serious attention to the mental state of these unfortunate women and be mindful of the risk to their life due to severe depression and suicidal ideation. Apart from incest and rape, embryos with serious congenital malformations should also be considered for termination when diagnosed early, as these children when born are a severe burden on the parents as well as the society at large.