A Situational Analysis On Abortion In Egypt
Prof. Ezzeldin Osman Hassan (Secretary General, The Egyptian Society
of Gyn. & Obst), Dr. Sahar El-Sonbaty (Head of Population Sector,
MOHP), Dr. Amr El-Ayat (Executive Director, The Egyptian Family
Planning Association), Dr. Nahla Abdel –Tawab (The Population Council,
Egypt), Ms. Mona El-Ghazaly (UNFPA office, Cairo), Dr. Fatma El-Zanaty
(DHS, Egypt), Dr. Ramez Mehana, (Regional office for Eastern
Mediterranean, WHO)
Unwanted Pregnancies
Egypt Demographic and Health survey ( EDHS ) , 2005 estimated that in the
five years preceeding the survey , 19 % of births were unwanted  7 %
admitted that it could be wanted at a later time and 12% that it was not
wanted at all . The proportion increases directly with birth order and with
increasing age of the mother so that two fifth of all fourth and higher
pregnancies were unplanned compared to only about 15 % of second order
births .

The determinants of unwanted pregnancies were :
-
Lack of access to contraceptive services 1 %
-
Contraceptive method failure 8.7 % for all methods.
( 23.3 %
for condoms , 15 % for both oral contraceptives and LAM )

The number of unwanted pregnancies among the unmarried and those
occurring as a result of rape cannot be estimated .

The percentage of unwanted pregnancies that end in abortion is
unknown .

Barriers for contraceptive use among currently married women were :
-
Lack of contraceptive Knowledge
0.1%
-
Lack of access to contraceptive services
0.1%
-
Husband opposition to contraceptive use
3.3%
-
Health concerns and fear from side–effects
of contraceptive methods
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16.9%
Contraceptive information and services including EC

59.2% of currently married women use a contraceptive method ( EDHS
2005 ) . The percentage being more in urban than in rural localities

-
3.6 % use the IUD
-
9.9 % use the Pills
-
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-
0.8 % use implants
-
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-
1.3 % use sterilization
-
2.7 % use traditional methods
% use injectables
% use condoms
All the contraceptive methods are available in all service outlets and
some at subsidized prices
-
Implants are available in some outlets
-
sterilization is provided in secondary and tertiary health care
levels
-
Progestagen-only Emergency Contraception is registered and
available in pharmacies to private sector and also available to
public health service outlets . However , physicians rarely
prescribe it either because they do not know it or because they
think – wrongly – that it causes abortion
-
Contraceptive methods are available in the pharmacies even to
the young and to the unmarried . But there are no data on the
number of users in this category .
Comprehensive Sexuality Education

In general , knowledge about sexuality is poor even among married
couples .

Information about the anatomy and physiology of male and female
reproductive system , conception and contraception is included in the
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curricula of the general education . But there is no comprehensive sex
education program .

Teachers apparently lack adequate training to teach the already set
curriculum . Some are reluctant to teach it for cultural reasons .
Social protection of pregnant women and mothers and small children

The law prevent employment of pregnant women in circumstances that
can adversely affect pregnancy or the infant and this is enforced .

After delivery , all women are entitled for one and a half months paid
leave , but the leave becomes unpaid after the second birth.

All women are also entitled for two years unpaid leave after delivery to
take care of the child .

Breast feeding is protected as all breast feeding women are entitled to
be absent from work for one paid hour every working day to breast
feed their babies for two years .

All public and private institutions comply with the law on parental leave
and maternal breast feeding .

Some employers provide a free ( or with nominal fees ) space to host
breast fed children of their working women . There are private day
nurseries for children of working mothers but their number may be
becoming less compared to the increasing labour force of women .

The law also prohibits employment of children .
Adoption
Adoption is not legal in Egypt . However , families can have orphans or those
of unknown parents to live with them and bear their expenses . This is subject
to very strict regulations and supervision to ensure that those children are not
ubused .
Abortion
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
Women admitted that 10.5 % of their pregnancies ended abortion (
EDHS 2000 )

There are few reliable data on the incidence of abortion in the country .
However , a study conducted by the Egyptian Fertility care foundation
and the population council in 1997 to estimate the caseload of abortion
in public hospitals revealed that :
-
Public hospitals treat about 336000 cases of abortion every year
.
-
19% of OB & Gyn admittions in hospitals are cases of abortion
-
According to WHO Classification ,
 5% are classified as certainly induced
( evidence of trauma or the patient admitts induction )
 35 % are classified as spontaneous ( no signs of trauma
and the women admit that the pregnancy was planned
and wanted )
 58 % are classified as possibly induced
( presence of sepsis or women admitt that the pregnancy
was unwanted )
 2% are classified as probably induced
( presence of sepsis and the women state that
pregnancy is unwanted )
The study also showed that :

about 26% of women admitted for abortion were 20-24 years old and a
similar percentage were 25-29 years old .

61 % of women were illiterate .

The mean parity was 2.61.

8 cases died out of 4153 women ( fatality rate 0.43 % per 100
admissions .

Abortion cases were managed by physicians , mostly by dilatation and
curettage . Few centres perform manual vacuum aspiration .
Induced abortion
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-
3 % of women admitted ever having an induced abortion (
EDHS , 1995 )
-
The same figure was reported as 2.3 % of women in a study
conducted by The Egyptian Fertility Care Society on the
prevalence of maternal morbidity in Menofeya governate ( 1995
) . This study reported that70 % of induced abortion were
because women want no more children and that 13 % because
the pregnancy was unexpected . Twenty nine percent of women
reported that they were not using a contraceptive at the time of
occurrence of pregnancy but 59 % were using modern method
of contraception . The abortion was induced by a physician in 27
% of cases . Complications occurred among 50 % of those
induced abortions , excessive bleeding in 41 % and fever in 26
% . About 25 % of those women seeked medical treatment ,
the place being a governmental hospital in 69 % of cases . The
figures for women who admitted even having an induced
abortion may be underestimated as this figure was reported as
14.8 % in another study ( Huntington , 1998 )
Abortion Contribution to maternal mortality :
The National Maternal Mortality study ( 2000 ) estimates that abortion
contribute to 4 % of direct obstetric deaths and 4 % of all maternal deaths ( 55
% judged to be spontaneous abortions and 45 % to be induced abortions .
Study findings suggest that induced abortion is a less significant problem in
Egypt compared to other countries .
Unsafe abortion

Data on unsafe abortion are few and inconsistent .
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
An overview of 12 hospital based studies ( El – Mouelhy , 1987 ) found
that the proportion of induced or septic abortion reported by those
studies varied between 1.7% to 60% .

Unsafe abortions are performed by physicians in private settings or by
nurses and traditional birth attendants at home.

Most women subjected to unsafe abortion are married and having
children . However , an unknown percentage
must be among
unmarried young girls .

Physicians perform abortion either surgically ( D&C or MVA ) or
medically by misoprostol that is available in the pharmacies but
registered only for the treatment of peptic ulcer .
Nurses may induce abortion by introduction of a foreign body or by
misoprostol .
Traditional birth attendants perform abortion mostly by introduction of a
foreign body .
Quality of care for women consulting complications of abortion

Cases of incomplete abortions are treated
by physicians in
governmental and in private settings .

All secondary and tertiary public and private facilities are equipped to
deal with incomplete abortion . The service is provided free in public
hospitals .

The above mentioned facilities deal with all cases of incomplete
abortion even among the unmarried . But some of this last group may
refrain from seeking services early enough because
of cultural or
financial reasons if they are aiming at private services . Physicians are
required to notify the police if they suspect the abortion was induced .

All physicians are being trained on the management of incomplete
abortion . However they will not practice it except if they are working at
secondary or tertiary health care levels or in their private clinics .
Consequences of unsafe abortion
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
As mentioned , the 4 % contribution of abortion to maternal mortality
may be an underestimation .

Hospital based studies report an incidence of infection in 1.7 – 60 % of
cases

The Ministry of Health and population monitor maternal mortality
frequently . However , monitoring abortion related Maternal mortality is
performed in National maternal mortality studies .
Legal situation of abortion and regulatory framework

Abortion policy in Egypt is classified as
rather restrictive in that
abortion is only permitted when pregnancy endangers women’s life .
However , even if termination of pregnancy is needed because of a
health reason and within the prescribed 120 days , abortion is an
extremely delicate and sensitive issue , Because of these restrictions ,
the availability of safe abortion services in Egypt is limited particularly
for poorer women in public health facilities .

Up till now , abortion is not permitted in cases of rape . However , a
recent religious opinion “ Fatwa “ from top Islamic religious leaders
permit induction of abortion before viability in those cases, but the law
had not been changed .

Abortion is permitted on medical grounds
for severe foetal
malformations incompatible with life . There is nothing mentioned in the
law about permitting abortion in those cases , the law criminalizes
abortion in general . However , the general principles of law may make
abortion permissible in certain cases .

Abortion is not permitted for socio-economic reasons or as a woman’s
choice .
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Provision of legal abortion services

Compliance with the abortion law is not absolute and illegal abortion is
sometimes being performed in non-governmental settings .

For legal indications , abortion can be performed surgically by D&C or
MVA or sometimes medically by misoprostol .

In theory , legal abortion services are available freely in public hospitals
. However
, as stated, cultural and religious sensitivities limit the
availability of those services particularly for poorer women in public
health settings . In that case , two physicians should sign a report
explaining the exact reason for abortion induction .

Legal abortion services are not available for the unmarried .

Obstetricians and Gynaecologists are trained on how to induce legal
abortion medically and by D&C and some are trained on MVA .

Misprostol is registered only for the treatment of peptic ulcer and is
available in the pharmacies .

FIGO ethics committee recommendations are recognized and followed
by the OB & Gyn society within the permissions provided by the law
and the Islamic law or “ Shareea “
Situations of restrictive laws

According to the Egyptian law , women are prosecuted and jailed if
they subject themselves to illegal abortion .

Confidentiality of health records for care of women is observed in
private services but not in public health services.

According to the law, physicians are prosecuted and jailed if they
perform illegal abortion and their punishment is more severe because
they are members of medical associations.
In general , the Egyptian law :
 Do not specify a gestational period
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 Do not permit induction of abortion on women’s
request
 Do not recognize any motive for induction of abortion.
 Prosecute whoever induces abortion even the
women herself .
The punishment for induction of illegal abortion is
more severe to members of the medical team .
 Physicians should notify the police if they suspect the
abortion being illegal.
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