Opening the Dialogue: A First-of-Its-Kind Exploration into Ethics of Termination of Pregnancy

By Arshad Khushdil¹, Muhammad Fayyaz¹, Madiha Ahmad², Afeera Afsheen³, Imran Ahmad⁴, Zeeshan Ahmed¹

Affiliations

1. Department of Paediatrics, Pak Emirates Military Hospital, Rawalpindi, Pakistan
2. Department of Gynaecology and Obstetrics, Fauji Foundation University, Rawalpindi, Pakistan
3. Department of Gynaecology and Obstetrics, Pak Emirates Military Hospital, Rawalpindi, Pakistan
4. Department of Paediatrics, Isra University, Hyderabad, Pakistan

doi: 10.29271/jcpsp.2025.04.524

ABSTRACT
Objective: To evaluate the perspectives and practices of Paediatricians and Obstetricians in Pakistan regarding termination of pregnancy (TOP).
Study Design: A cross-sectional survey.
Place and Duration of the Study: Department of Paediatrics, Pak Emirates Military Hospital, Rawalpindi, Pakistan, from January to March 2024.
Methodology: Convenience sampling was used to recruit 69 participants from the paediatrics and obstetrics departments in various healthcare settings in Pakistan. A structured questionnaire was developed by reviewing relevant literature and administered electronically using Google Forms. The participants were contacted through professional networks, associations, and email listservs. The questionnaire comprised four sections: Demographic information, knowledge evaluation, attitude assessment, and practice-related exploration. Descriptive statistics were used to calculate frequency and percentages.
Results: A significant number of participants, 51 (73.9%), had not attended any TOP-related talks or workshops. More than 90% of study participants believed that both spouses should provide consent for TOP, and 52 (75.4%) were in favour of TOP post-ensoulment due to severe foetal anomalies. However, 46 (66.7%) participants were against TOP and considered themselves pro-life.
Conclusion: The area needs more focus during teaching at both undergraduate as well as postgraduate levels as this study shares a very clear picture that residents and consultants lack knowledge of the basic definition of the concepts of TOP.

Key Words: Induced abortion, Beginning of human life, Paediatrics, Obstetrics, Knowledge, Attitudes, Practice.

INTRODUCTION

Pregnancy is a cradle of physical germination and formulation of humans, which is sometimes marred by misalignments, malformations, and even the complete absence of some systems of the body that are essential for life, leading to anomalous foetuses.¹ Globally, 7.9 million children are born with birth defects incompatible with life annually.² According to WHO, 6% of all births have congenital disorders, which are disproportionately high in low- and middle-income countries (94%).³

These conditions pose significant public health challenges. The economic, social, and cultural underpinnings related to such births are enormous and felt by all affected.⁴
 

The shortage of specialised facilities, trained personnel, and inadequate knowledge on handling them lead to a very high degree of unsafe abortions, especially in an environment where the unplanned pregnancy load is very high.⁵

These special cases are not rare but rather a regular feature of practice in Pakistan, posing the same challenges encountered worldwide. Only one-year of data from a tertiary set-up in Mardan indicated 18% anencephaly, 11% meningomyelocele, and 9% encephalocele.⁶ A similar situation was presented by Bibi et al.⁷ These conditions require medical professionals to make difficult decisions about the foetus and to preserve the life and health of the mother, which include interruption of pregnancy in certain situations as a medical indication.

It is essential for all healthcare professionals to not only be technically competent in their craft to diagnose such conditions but also be sensitive to such multifactorial angles and ethical underpinnings. They should play a facilitator’s role and help parents make the right decision. Physicians can benefit from surveys that assess their knowledge in certain areas, as this allows for a better understanding of their strengths and weaknesses. These surveys can also help identify gaps in knowledge and inform the scientific community about the development of targeted training programmes.

This study aimed to elucidate the level of knowledge, attitude, and practice of different categories of physicians working in departments of obstetrics and gynaecology, and paediatrics about ethical issues revolving around the start of life conditions, which may require termination of pregnancy (TOP), also known as induced abortion.

METHODOLOGY

This was a cross-sectional study conducted at the Pak Emirates Military Hospital, Rawalpindi, Pakistan. It employed convenience sampling to recruit healthcare workers (HCWs) working in the departments of obstetrics and gynaecology, and paediatrics in various healthcare settings in Pakistan. A structured questionnaire was developed by reviewing relevant literature and administered electronically using Google Forms. The participants were contacted through professional networks, associations, and email listservs from January to March 2024. Participants were informed of their right to withdraw from the study at any time and were assured of the voluntary nature of their participation.

The researchers used descriptive statistics, such as frequency and percentages, to summarise the participants' demographic characteristics, knowledge, attitudes, and practices regarding TOP. The study received ethical approval from the Institutional Review Board, and informed consent was obtained from all participants before their participation in the study. The confidentiality and anonymity of participants' responses were ensured throughout the study process. The results were entered in a Microsoft Excel sheet and analysed in the Excel sheet.

RESULTS

The questionnaire was completed by 69 participants. Of these, 46 participants were females (66.7%), while 23(33.3%) were males. The demographic characteristics of the participants are provided in Table I.

In the knowledge section, participants were asked about the basic definition of TOP, and the majority 37 (53.6%) stated that TOP is the termination of pregnancy before 24 weeks of gestation. Only one participant (1.4%) chose the correct option of ending a pregnancy for maternofoetal reasons that are medically or ethically justified, whether the foetus is alive or dead.

In terms of indications for TOP, the participants were divided in their opinions, with some advocating for TOP for maternal reasons and others supporting it for foetal reasons before the 19^th week of gestation. When asked about the reasons in favour of TOP when there is no threat to the mother's life, the majority of the respondents cited the sanctity of the mother's life as justification. However, many participants were not familiar with arguments against TOP.

A significant number of participants, 51 (73.9%), had not attended any TOP-related talks or workshops. Regarding consent for TOP, 63 (91.3%) of the participants believed that both spouses should provide their consent. Additionally, 52 (75.4%) of the participants were in favour of TOP post-ensoulment due to severe foetal anomalies.

While 32 (46.4%) of the participants were aware of the Islamic injunctions related to ensoulment, more than half of the participants were familiar with Pakistani law allowing TOP for severe foetal anomalies.

In the present study, 46 (66.7%) of the study participants were against TOP and considered themselves pro-life, while 38 (55.1%) believed that TOP should not be allowed under any circumstances. Generally, Pro-lifers were not rigid in their stance and may have accepted a TOP with a logical reason such as incest/adultery/rape.

According to the present study, 44 (63.8%) of the participants reported that they had never received a request for TOP without any reason, and 28 (40.58%) indicated that a cut-off age of 24 weeks for foetuses was the maximum age for TOP.

DISCUSSION

Humans are amazing creatures, who like to have things in black and white – always clear – but the real answers to life's difficult questions are mostly in grey. Medical ethical issues are one of those. It requires practitioners of the medical profession to explore and understand the intricacies of existence, in addition to technical and scientific knowledge of medicine and individual clinical specialities.

Table I: Demographic characteristics of the study participants.
 

Characteristics	All healthcare professionals		Obstetrics and gynaecology		Paediatrics
	N	%	N	%	N	%
Gender
Male	23	33.3	0	0	23	33.3
Female	46	66.7	16	23.2	30	43.5
Professional experience
First-year resident	13	18.8	2	2.9	11	15.9
Second-year resident	14	20.3	1	1.4	13	20.3
Third-year resident	12	17.4	1	1.4	11	15.9
Fourth-year resident	5	7.2	0	0	5	7.2
Senior registrar	10	14.5	4	5.8	6	8.7
Assistant professor	6	8.7	3	4.3	3	4.3
Associate professor	4	5.8	1	1.4	3	4.3
Professor	5	7.2	4	5.8	1	1.4

This study was conducted to understand this aspect. Nearly all participants had limited knowledge of TOP's fundamental definition. Only one participant, who was a professor of obstetrics and gynaecology and had over 25 years of clinical experience, provided the accurate definition of TOP, which refers to ending a pregnancy for a maternofoetal reason that is medically or ethically justified, regardless of whether the foetus is alive or dead. All but one second-year resident of obstetrics and gynaecology favoured advising TOP in cases of severe congenital malformations, even after 24 weeks of gestation.

The majority of HCWs working in the paediatrics department 33(47.8%) were also of the opinion to advise TOP after 24 weeks of gestation due to severe foetal anomalies. However, only 6 out of the 33 HCWs of the Paediatrics Department were at a consultant post, while the remaining 27 were still undergoing training. The reason might be that the majority of those had no idea of when TOP was allowed legally and religiously in Pakistan or its desire as they are the ones in the paediatrics department who find themselves midst of these situations daily. This is an important revelation, showing gaps in knowledge leading to a lack of consultative capacity.

A similar study conducted in Saudi Arabia demonstrated improved knowledge, attitudes, and practices among healthcare workers, which were linked to training and education in biomedical ethics.⁸ This underscores the importance of implementing structured training and education in bioethics. This study indicated that 74% of the participants had never attended a talk or workshop on TOP, which further enhances the conviction that there is an essential need to arrange educational sessions and structured training programmes on biomedical ethics and practical issues faced by HCWs.

The little exposure of residents and physicians to Medical Ethics seems to be the reason that the majority 52 (75.4%) thought to terminate a pregnancy even after ensoulment if there are severe foetal malformations. This level of understanding shows a fundamental lack of knowledge on the subject, which is direly required for proper practice in general, and in a Muslim society in particular. If we look at the world canvas, many laws and customs exist in different parts of the world. However, WHO has issued a framework with six primary grounds that can interrupt pregnancy.⁹ In Pakistan, the current Pakistan Penal Code in Sections 338, 338A, 338 B, and 338C deal with this matter, with two terms: Isqat-e-haml and Isqat-e-Janin as offences only dealing with the illegal side of the matter.¹⁰ The difference between the two is the formation of foetal organs, which is not defined in terms of the time frame that occurs during pregnancy.

Until 1997, Pakistani law about allowing TOP (calling it abortion) was restricted to the life of the mother only, when by presidential ordinance, treatment of mother injunction was added to it as a legitimate reason for TOP. The law is silent on foetal conditions and is completely missing in pregnancies arising from rape and incest. Azmat et al. conducted an extensive qualitative study covering legal stakeholders, prison officials, physicians, police officials, and judges in Pakistan and revealed less understanding and cognisance of these issues of pregnancy. They have a predominantly cultural and crime/punishment lens when defining the legal understanding of these matters.¹¹ Therefore, a medical fraternity wields huge power to make such decisions and has full legal cover without attaching many strings, and it has its advantages and disadvantages. It puts a heavy burden on the shoulders of the healthcare providers to improve upon their knowledge and apply it ethically and judiciously.

The detailed corpus linking the legal and religious angles on the subject shows various facets and details in the Pakistani context.¹² Islamic jurisprudence does not have much discussion about when life starts or is equal to the start of life, the way it is done in modern times today. This contentious issue, however, led to a final fatwa from the Islamic Jurisprudence Council of Makkah in its 12^th session in 1990, allowing interruption of pregnancy before 120 days, which is ensoulment time, because of mother or foetal issues. No rule in Islamic law exists that allows interruption of pregnancy after the ensoulment time (120 days) because of foetal anomalies; however, on medical judgement to save the life of the mother, the interruption can be done even after 120 days.¹³ Jafri et al., in their research letter, discussed different fatwas on TOP and concluded that HCWs need to know them in detail for better patient care.^14,15

The main limitations of the present study are the limited number of participants from the obstetrics department and the limited number of participants from the senior echelon.

CONCLUSION

This study underscores the importance of increased training in TOP for healthcare workers to mitigate the risks associated with unsafe abortions and terminations. Policymakers should prioritise public health and social justice by revising laws and regulations related to TOP to promote public awareness, understanding, and education. Additionally, incorporating training on TOP, including ethical considerations and legal frameworks, into the curricula of relevant clinical specialities is crucial.

ETHICAL  APPROVAL:
The study was conducted after approval from the Ethical Committee of the Institution (Approval No: IRB-A/28/ER/58/24, Dated: 5^th January 2024).

PARTICIPANTS’ CONSENT:
Informed consent was obtained from all participants before their participation in the study.

COMPETING INTEREST:
The authors declared no conflict of interest.

AUTHORS’ CONTRIBUTION:
AK: Conception of the idea, data collection, article drafting, and final review.
MF: Drafting of the article, critical review of the manuscript, and final review.
MA, AA, IA, ZA: Revision of the manuscript for important intellectual content.
All authors approved the final version of the manuscript to be published.

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