kien svay district, Kandal province – The procedure is as old as it is dangerous, said Keo Sokha, a traditional Cambodian midwife.
There is an old woman, she said, who can feel around on a woman’s swollen stomach, prodding with her fingers until she finds the still-developing fetus.
With her hands on the pregnant woman’s bare skin, the old woman can judge the size and shape of the fetus. She then squeezes the small shape until its neck breaks.
“Many women have dangerous abortions,” Keo Sokha said. “They do not want to do it like this. But they have to do.”
While reliable abortion services are more accessible than in the past, the cost means many rural women still use methods they can administer themselves or can obtain from traditional doctors or midwives.
Abortions are performed daily in Cambodia, but health officials do not have statistics on how many are performed. They also do not know how many women die each year from botched procedures in private clinics, by traditional doctors or by pregnant women themselves.
Keo Sokha has assisted in the births of thousands of children since first learning her trade 30 years ago in Svay Rieng province. She can name families in which she has delivered every one of the children.
But large families are becoming a thing of the past, she said. Once large families were considered fortuitous, but now they are a burden on desperately poor people, she said.
And women who have been unable to prevent pregnancy increasingly are having abortions, said Keo Sokha.
Recovering after an abortion procedure, a 20-year-old patient at the Cambodian Women’s Clinic in Phnom Penh said she hopes to have children one day.
But until then, she wants to avoid getting pregnant. She has had three abortions.
Doctors at the clinic have told her about contraception, she said, but she hasn’t had much luck in making it work. She used daily contraceptive pills, but forgot to take them. Condoms could be an option, but she’s not sure her husband will use them. Now she is turning to traditional Chinese medicine.
“I’ll try a traditional Chinese pill that I only have to take once a month,” she said. “One pill a month is easy to take.”
Dr Keo Mao, director of the Reproductive Health Association of Cambodia, said it is impossible to assess the number of women having abortions in Cambodia as the majority are performed in unregulated private clinics or by traditional midwives in rural areas.
While abortion has always been available for specific reasons such as rape, it is now commonly used by women who, for economic reasons, cannot provide for another child.
But the cost, or perceived cost, of a hospital abortion means it is still more common for women to seek traditional Cambodian methods or Chinese medicine, Keo Mao said. Everything from drinking excessive amounts of alcohol to inserting mixtures of herbs and tree bark into the cervix are used, she said. The procedures or medicines often cost less than $2.
In many cases, the methods are enough to kill the fetus, but that doesn’t mean the fetus will leave the woman’s body.
“One woman came to us with serious bleeding from the uterus. She told us she had taken Chinese medicine to induce an abortion. She had lots of bleeding but no abortion,” Keo Mao said.
Kandal province midwife Khat Yen, 58, learned her skills during the Khmer Rouge regime when she was sent to a hospital in Battambang province after being evacuated from Phnom Penh.
Watching other midwives at the Khmer Rouge-run hospital, Khat Yen soon picked up methods of child birth that did not rely on medication or instruments.
Despite the crudeness of the methods she has learned, Khat Yen said they have sufficed for hundreds of women who could not afford more than what she offered.
She’s also proud that she has not performed an abortion. But she said abortions are common, and on many occasions she is called to care for women who have attempted abortions on themselves.
“Each life is very important,” she said. “I won’t do [abortions]. Each life must see the sun. But I am usually called to clean up afterwards.”
Dr Prak Somaly, vice director of the technical bureau at the National Maternal and Child Health Hospital in Phnom Penh, said the hospital conducts more operations to fix botched abortions than actual abortions.
In 1999 and 2000, the hospital performed 204 abortions of its own but cared for 308 women who suffered serious complications after having abortions elsewhere. Ten of the 308 women died from complications, he said.
Women who come to the hospital rarely disclose how the abortion was performed or who performed it. Reluctance to share information has prevented authorities from keeping accurate and detailed statistics on abortion trends and demographics, or tracking down people who perform botched procedures.
“We cannot stop abortion because we have a law,” Prak Somaly said. “But we must control those who do abortions so that it is safe and reduces the number of women who are casualties of badly performed abortions.”
He said the Ministry of Health could do a better job of controlling private abortion clinics.
A draft ministerial directive regulating abortion states that the procedure can only be conducted at either public or private clinics, and health centers or hospitals which have been authorized by the Ministry of Health. Only qualified doctors, nurses and midwives authorized by the ministry can perform the procedure.
Failure to comply can lead to a clinic being shut down and the person who performed the operation being suspended from practicing medicine.
Unqualified people who perform an abortion can be imprisoned for one year or up to five years if a woman is injured as a result of the operation. If a woman dies during an abortion, the person who performed it can be imprisoned for five to 10 years.
There have been no prosecutions for botched abortions under this law, said Man Bun Heng, secretary of state at the Health Ministry.
The ministry contends abortions are decreasing as the numbers of people using contraception has increased significantly since 1994.
But staff at the Leng Choeu Chinese Medicine Store on Kampuchea Krom Boulevard say they do brisk business in sales of medicine for abortions.
The Chinese tablets, $10 for a packet of six, can be used up to the 49th day of pregnancy, though some women have used it as far as two months, said a staff member.
The tablets, taken on an empty stomach, cause the body to reject and expell the fetus. “It’s very safe,” the staff member said. “Many people use it. They never have problems.”
(Additional reporting by Pin Sisovann)
