Women's Health Problems in Pakistan

A Brief Background
Ours is a male dominant society where only very few females enjoy full rights and have
access to opportunities of even very basic human needs. This is even more true in the
health sector, where unfortunately there is a great lack of female doctors combined with a
large number of female 'quacks' in the country and the situation is at its worst in
Shamsabad where there is only one or two qualified female doctors. The female doctors
are neither easily available nor easily affordable and women do not prefer to be examined
by male doctors.
There are a lot of government hospitals which provide free or low fee treatment to
women but those are not preferred because of:
- The casual and offhand behaviour of doctors
- More than one male doctor examining the patient at one time
- The fear of crowds of medical students present at time of examination
- The fear that doctor may misuse this opportunity for some evil deed
Right from the beginning of my career, I have had very strong intentions to organize the
primary health care system in my area and to make my clinic a model for others. Towards
this end, I was very fortunate because I became involved with two very useful people, Dr
Christopher Rose, PhD, Ex. Executive Director, Action in International Medicine (AIM) ,
London,UK and Dr Barry H. Smith, MD, PhD, Director of Dreyfus Health Foundation (
DHF ) , New York, USA. The two organizations were jointly operating a very famous
Programme called CCI-Programme.
CCI Programme Training Workshop
Dr Rose visited Pakistan twice, in 1998 and 1999, at my request. We had identified the
Top Ten Health Problems of Shamsabad List during his last visit. Women's health
problems were on the top of the list. (The term Women's Health Problems is strictly used
to indicate only those health problems, which are specific to women).
Dr Christopher and I had decided to address these problems through the CCI-Approach,
but this was not possible due to lack of funds because of the collapse of AIM. We did not
receive any funds, from any organization.
I was left with three choices:
a) Continue searching for the funds from other sources
b) Quit the mission
c) Continue the mission with my own personal resources at a very small scale through my
clinic.
The first two were not possible for me due to many reasons, therefore, I decided to act on
the third option and hence started to follow the PSBH1 - approach in my clinic.
Dr Barry H. Smith is an eminent neurosurgeon, development scientist and social work
expert. Dr Christopher Rose is a renowned scientist, development & social work expert
from Glangors, UK. Although the CCI-Programme does not exist anymore these two
gentlemen are kind enough to consistently provide their moral support and guidance for
our work.
Before starting the work, it was necessary to have some insight into the prevalence and
magnitude of the most pressing health problems of women living in Shamsabad.
Therefore, all the women attending my clinic for any reason were questioned about their
(women's) health problems for one month and the following most pressing women's
health problems were identified.
Later, some conclusions were drawn, from this data, in a very crowded free camp held in
my clinic on the second Sunday of July, 2000.
The main problems were:
1) Vaginal discharge
2) Unwanted pregnancies in married women
3) Breast Problems
4) Malnutrition
5) Menstrual disorders
Strangely, only a few indicated the lack of facilities for Antenatal care and problems
caused by childbirth by traditional birth attendants who are uneducated and lack training.
To make the list more real and practical, the problems were re-numbered as follows:
1) Lack of facilities for antenatal care and childbirth
2) Vaginal discharge
3) Unwanted pregnancies in married women
4) Breast Problems
5) Malnutrition
6) Menstrual disorders
Defining the Problem: The women's health problems were discussed during different
workshops in Shamsabad which were attended by cross section of the community and the
following were identified as aggravating factors:
Lack of medical facilities,
Ignorance,
Lack of nutritional facilities,
Prevalent social environment,
Psychological factors,
Unemployment and Poverty
How we are addressing the problems?
The Logistics
Maqbool clinic, a General Practice clinic, has been owned and operated by myself since
1986. It is situated in Shamsabad, Dhoke Kala Khan, Rawalpindi very close to
Islamabad. The surrounding area is densely populated (approximately, some 100,000)
where a number of Afghan and Pashtoon refugees of Afghanistan live among local mix
urban, suburban and rural population.
Mrs. Rahila Manzoor (my wife) is a locally trained health technician who can perform
vaginal examination and take HVS and Pap smears. She is playing a vital role in this
work. The clinic always has at least one nurse capable of dealing with women. It was
decided that Mrs. Rahila would first examine the patients and if she found something
requiring examination by a doctor, the patient would be given a choice to either have a
pelvic examination by myself but if she refused, referral to hospital female doctor with a
full personal reference from us. I had already trained and upgraded my skills in obstetrics
and gynaecology via further training from friend Gynaecologists, and via the internet and
audio-video aids. The necessary skills were then taught to Mrs. Rahila .It was decided
that expenses for the women's health project would be met from income of our clinic's
other routine activities and all income from this project would be utilized to add facilities
for enhancement of our activities.
There was no pathology laboratory near my clinic. There was a great need for a
laboratory that could provide quality results at low price for our "Women's Health
Project", especially those essential during antenatal period. I was already doing blood
sugar testing, urine sugar testing and pregnancy tests in my clinic from my own
resources; but there was an immense need to initiate the following very important tests:
Blood grouping, Haemoglobin Estimation, ESR, urine screening for sugar and
albuminurea, urine routine examination, screenings for Hepatitis-B, Hepatitis-C and
HIV/AIDS.
I had some savings from my clinic's income for this purpose. I used that money to buy
the essentials. We have a part time laboratory technician. I had already refreshed my
pathology knowledge and skills and undertook training in these tests. I have been
performing these tests since 2002. I have kept the rates at a level which is affordable for
all patients and I do these free for the very poor. I am using Standard Control Technique
to prevent false results. Our patients have benefited not only via the affordabe costs, but
also get quality results without going very far. To keep it self sustainable, all income
from the laboratory is being reinvested to buy the diagnostic reagents and material.
What was the main obstacle?
The main obstacle was that no-one could imagine that women would have an
examination by a GP who is operating a clinic right near their homes. The following were
identified as restraining factors:
* The concern as to how they could face this person again
* What if my husband finds out?
* The fear that someone may peep in during examination
* The fear that the staff of clinic would disclose this information to my
neighbours/relatives.
How we overcame these problems
First of all, I established an all day help line (from 06am to 01 am) which provided free
advice and guidance for medical and social problems of patients. I am proud to inform
you that I have saved lives of many innocent girls who were at the point of committing
suicide because of their social circumstances. My clinic is more of a social welfare office
and we are available for everyone regardless of faith and religion.
I respect every patient, especially women. I always reassure our reluctant patients that
having a physical examination is not a sin on their part nor any opportunity for me to do
some evil. I inform them that a doctor is fully aware of the human body and when he
examines private parts of a female, it is for benefit of women and not for satisfying his
evil feelings. Right from the start, I referred to patients as relatives, such as sister,
daughter, and aunt so that they should understand I do not have any evil feeling for them.
To overcome other difficulties, we took the following steps:
1) The examination room of my clinic permits complete privacy
2) During examination, my wife or a female nurse is always present
3) Patient is allowed to bring in one of her relative or friend into examination room
during check up, if she likes.
4) All information regarding a patient's examination and disease is kept fully confidential,
even from the husband if the woman demands. If she is suffering from some serious
problem, we always encourage her to take the husband into confidence.
To address the problem of lack of awareness among women about the importance of
Antenatal care and complications of childbirth by non-qualified, non-trained midwives,
the following question was formulated:
Question
Will a Programme of motivation and awareness about the importance of antenatal care
and childbirth by a trained and qualified midwife/hospital staff whether at home or in
hospital, organized at Maqbool Clinic, Dhoke Kala Khan by Dr Manzoor, Mrs. Raheela
Manzoor, Miss Sobia , Miss Shabana & Miss Sajida (local volunteers) for one year, for
pregnant women of Dhoke Kala Khan, create awareness at least in 30% of those
attending the clinic?
The activity was initiated formally on 01-05-2000. All pregnant women attending our
clinic were informed about the presence of Antenatal centers in the city and they were
encouraged to visit such free government centers for antenatal booking and delivery.
They were informed about the importance of:
(a) Diet during Pregnancy
(b) Regular Blood pressure checkups
(c) Regular weight measurements
(d) Regular fundal height checkups
(e) Hb % determination
(f) Blood /Urine Sugar determination
(g) Blood group determination
(h) Determination of foetal well being through ultrasound examination
(i) Immunisation against Tetanus and Hepatitis
During 2001, this activity was performed with about 700 women . The outcome was
greater than expected. Many women now come to us for antenatal checkups. Their
number is at least five times more than those who were coming to us previously.
It was realized that the following activities are urgently needed to augment this effort:
a) More organised Antenatal checkup facilities including basic relevant tests at our clinic
b) More advocacies for ultrasound examinations and hospital delivery
c) The most important of all is the availability of resources for training of local midwives
who are already popular among women.
We are already performing pregnancy tests, blood sugar measurements, and urine sugar
/albumin measurements and immunization against tetanus.
To address the problem of vaginal discharge in married women, the following question
was formulated:
Question
Will a Programme of "health education and affordable facilities of pelvic examination,
HVS study, Pap Smear test, specific treatment of infections and, referral of difficult-totreat
cases to a gynaecologist" at Maqbool Clinic, Dhoke Kala Khan organized by Dr
Manzoor, Mrs. Raheela Manzoor, Miss Sobia (clinic nurse), Miss Shabana & Miss Sajida
(local volunteers) and other supporting persons/organizations for one year for women of
Dhoke Kala Khan reduce the incidence of vaginal discharge by 25% in those coming for
guidance and treatment?
The activity formally started on 01-05-00. Although the clinic had been operating since
1986 the following had to be arranged from the clinic's own financial resources;
A gynae-examination table, examination lights, examination instruments especially
vaginal speculums, sterilisation equipment, disposable plastic gloves, sterilised
disposable gloves, sterlisable gloves, accessories for pap-test and HVS and regular supply
of relevant medicines
During 2001, about 390 females came for examination. Out of these, 85 were virgins and
305 were married.
a) The virgins were only examined by naked eye and 35 out of these 85 were only having
a watery discharge. These women were reassured and provided with advice for better
personal hygiene; the other 50 were having monilia infection, confirmed by discharge.
They were given advice and treatment.
b) Out of 305 married women , one patient complained of foul smelling discharge after
birth. She came to the clinic on the 25th day postpartum. On examination, there was a
hole in her posterior fornix and there was lot of pus and bloody discharge coming out of
it. She was sent to hospital for admission but they sent her back. The next day, I used
personal resources to get her admitted to the Gynaecology ward. She died there on the
third day after admission.
- One patient was having VVF, she was referred to hospital for an operation.
- Thirteen patients were having third degree utero-vaginal prolapse with ulceration of the
cervix. They were referred to hospital for care.
- Fifty seven patients had second degree utero-vaginal prolapse. They were also referred
to hospital for care.
- Twenty patients were actually having stress incontinence, they were also guided to
hospital.
- Ninety were only having uncomplicated monilial infection. They were given treatment
and advice re better personal hygiene
c) The rest of the 123 women out of 305 had moderate to severe infections. They were
advised for HVS. Only 25 agreed and were later treated according to the laboratory
report. The rest of the 98 women were given treatment for two weeks; 70 responded very
well to treatment and were followed up successfully.
d) Our real problem was the remaining 28 women who were having very severe pelvic
infection and cervical ulcers. They were asked to have a Pap test. 15 did not come back, 2
went to hospital for this test with our reference, and 11 agreed to have a test at the clinic.
The laboratory report indicated that two were having borderline dyskaryotic changes.
They are being closely watched.
It was realized that there is a great need for health education regarding personal hygiene
and sexually transmitted diseases (STDs). The following very important observations
were recorded;
- Almost no women take a bath during menses (5 to 7 days)
- Almost no women take a bath before intercourse; they only bathe after intercourse and
at least 4 to 6 hours after the act
- Most women use pieces of old bed sheets during menses as a sanitary pad; only a few
use cotton and none were using sanitary pads.
- The majority of women do not wear suitable under clothes
To address the problem of unwanted pregnancies in married women, the following
question was formulated:
Question
Will a programme of "health education and affordable facilities for family planning for
married women of Dhoke Kala Khan at Maqbool Clinic, organized by Dr Manzoor, Mrs.
Raheela Manzoor, Miss Sobia, Miss Shabana & Miss Sajida and other supporting
persons/organizations for one year reduce the incidence of unwanted pregnancies by
10% in married women?
This activity was started at random in October of 1999 but we started to keep records
formally from 01-05-00. It is actually a joint venture with the Government of our
province, Punjab, and a very resourceful NGO called Green Star. The Government and
the NGO provide us with very cheap supplies of family planning medicines and
accessories and we in turn provide our non-profit service to the women of area. The NGO
has also organised training workshop for us.
During 2001, about 275 women came to us for advice regarding family planning. All of
these were briefed about available facilities and especially about "Emergency Family
planning". About 55 never came back for advice or services. 25 preferred an IUD and
were guided to nearby centres for insertion of the device as we do not yet have this
facility. Out of the remaining, 30 selected condoms, 117 started injections with us and 48
preferred pills.
Unfortunately, only 15 out of 117 took regular injections at an interval of two months for
one year. Only 10 out of 48 on pills came for a second month's dose because they were
reluctant to take the pill daily.
This activity was more of a failure because;
a) Women do not understand the importance of timing in the menstrual cycle
b) They have a lot of misbeliefs regarding medicines
c) Women do not have sex education knowledge
d) There are a lot of 'quack' medicines available in the market, which claim effectiveness
for one year if taken once a year.
There is a great need for health education, counseling and group discussions regarding
this problem
To address the problems of Breast disorders, the following question was formulated:
Question
Will a Programme of "health education and facilities for free training for Breast Self
Examination (BSE)" and affordable Breast examination, by Dr Manzoor and Mrs.
Raheela Manzoor at Maqbool Clinic, Dhoke Kala Khan for one year for women of Dhoke
Kala Khan reduce the incidence of breast problems by 20%?
The activities were formally started on 01-05-00 and till now only consist of examination
by me or my wife as well as referral of problem cases to hospital. I trained my wife with
the help of the Internet and via patient examinations.
During 2001, about 142 patients attended our clinic.
a) Fifty five were lactating women with acute infection; 29 were referred to hospital for I
& D, the rest were successfully treated with antibiotics and other supportive measures.
b) Thirty were young girls who complained of strange things palpable in breast.
Examination revealed no abnormality but normal glands. They were advised, reassured,
and given supportive treatment
c) 1 girl presented with sinus in the left breast following acute infection. She was also
successfully treated and is now receiving follow-up treatment by us as well as a surgeon
in hospital.
d) 1 woman was eighty years old with a hard mass in breast. She was referred to hospital
where carcinoma was diagnosed and the breast was removed. She comes to us for regular
follow-up.
e) 4 were discovered to have a lump in the breast and were referred to hospital where
biopsy had revealed benign tumor. These have been reassured and given supportive
treatment and advice for frequent follow-ups.
f) One unmarried woman of 33 years C/O discharge from nipple. She was referred to
hospital for biopsy which revealed nothing. We are following her up by taking a smear
from the discharge and we get it examined by a Pathologist every six months.
g) The rest of the women did not have any abnormality. They are advised to do "Breast
Self Examination" every month and come here for a check up after every six months.
The major problem in this sector is that women present very late because of their shyness
and the only answer to it is training of Breast Self Examination. We have purchased a
Pentium-111 multimedia computer from the clinic's own resources and we have begun
this training in groups.
To address the problem of Malnutrition, the following question was formulated:
Question
Will a Programme of " health education and facilities of affordable health supplement" at
Maqbool Clinic, Dhoke Kala Khan organized Dr Manzoor, Mrs. Raheela Manzoor, Miss
Sobia, Mr. Mumtaz (male nurse in the clinic), Miss Shabana & Miss Sajida (locak
volunteers) and other supporting persons/organizations for one year for child-bearing
women of Dhoke Kala Khan reduce the incidence of anaemia and malnutrition by 20%?
To address the very common problem of anaemia and malnutrition in women of
childbearing age of Shamsabad, we joined the Vitalet Project for Better Health. The
activity formally started on 28-11-00. I took training about nutrition supplements on 03-
10-00 from a very resourceful NGO named Social Marketing Pakistan.
It mainly consists of health education and facilities of affordable health supplements,
which comprise multi-vitamins, and essential micro and macro minerals product whose
market price is an 80-Pakistani rupee for one-month course. We get the supply of this
supplement from the NGO on a regular basis at the rate of eight rupee per pack and
provide our every registered malnourished patient at rate of ten rupees for one month for
the maximum of four months.
To generate more awareness about the importance of a balanced diet, we arranged a
general meeting of 35 women with a nutrition expert from an NGO in our clinic on 24-
03-01 and thereafter-another special meeting of 30 pregnant/lactating women with the
same expert on 21-05-01 in our clinic.
During these meetings, the women showed a lot of interest in the topic and we intend to
keep up these activities in future. During the year 2001, a total of 360 women and 5 men
were provided this supplement. Out of 360, some more than two dozen women were
identified as grossly malnourished. These needed more attention and extra effort. We
planned an initial three week diet programme for each of these which generally consisted
of:
- Half a litre of milk daily at the clinic for 21-days
- Ten multi-vitamin injections/or infusions at the clinic on alternate days
- High energy candies daily at the clinic for 21-days
- High energy biscuits daily at the clinic for 21-days
Every patient attended our clinic very regularly and at the end of the three week course,
each was provided with this health supplement free of charge for four subsequent months.
All costs of milk, injections, infusions, disposable syringes, candies, biscuits and the
health tablets was borne by the clinic. In addition, we provided about three hundred and
fifty rupees each to two patients for laboratory investigations. One of our patients was a
tailor and was unable to operate her hand driven machine. We provided her with a motor
and all accessories to convert her machine to a motorised sewing machine.
Menstrual disorders
A number of patients attend our clinic with menstrual problems. They can be divided into
two main groups.
Group-1 consists of girls aged between 12 to 25 and,
Group-2 consists of women above 25.
In Group-1, most girls presented with dysmenorrhoea, amenorrhoea, oligomeno- rrhoea,
and polymenorrhoea. These are provided reassurance, guidance and supportive treatment.
There is an increasing number of cases of young unmarried girls who present with
generalized hirsutism accompanied with either amenorrhoea or oligomenorrhoea.
Unfortunately, we are not capable of handling such cases because these require hormonal
investigations and need an expert in hirsutism. Hirsutism is not only destroying their
social lives but also inducing suicidal trends in these girls because they cannot afford
very expensive laser therapy.
In Group-2, most of the women presented with dysmenorrhoea, amenorrhoea,
oligomenorrhoea, and polymenorrhoea. These were provided reassurance, guidance and
supportive treatment. There are certain patients who require hormonal assays, diagnostic
D & C and other measures beyond the scope of this clinic. Therefore, at present we are
only providing guidance to such patients.
Our results generally
In the beginning only 5 % women consented for a pelvic examination by me.
Our efforts have seen gradual improvement. Most patients now prefer me to examine
them and this includes the very rich women who can afford expensive treatment by
women doctors, elsewhere. An important result is that now many husbands bring their
wives to us and they convince their wives to get a check up. Most women have
permission from their husbands or mothers in law.
Women have also seen that my attitude has not changed after examining them and now
they bring their mothers, grandmothers and relatives and tell them that they have been
examined by me. I always remember that I am a GP and not a gynaecologist, therefore, I
do not hesitate to refer patients to hospitals or gynaecolgists if I feel it necessary.
I am pleased to report that our women's health project is continuing quite successfully. I
have performed more than seven hundred pelvic examinations on record since it began.
Now I perform 2 to 3 pelvic examinations daily under strict hygienic conditions and
about 1 to 2 breast examinations.
We have been able to generate awareness about many issues including health education
and feminine personal hygiene (especially during menses and personal relationship with
husband); general health issues; vaginal discharge and pelvic diseases; family planning
both regular and emergency); sexually transmitted diseases; Breast examination;
(especially the importance of early diagnosis of lumps) and antenatal, intranatal and
postnatal care. A lot of work is still to be done but our pace is satisfactory, if not good.
We are also committed to help increase women's income.
I have introduced the concept of breast self examination in this community and there is
increasing awareness about the importance of early detection and management of breast
lumps. Towards this end, I have diagnosed five cases of carcinoma of breast during this
year. I referred a real sister with one of these cases for prophylactic mammography which
turned out to be another case of carcinoma at so small a size it could not be palpated. We
always refer the suspected or high-risk patients to relevant government centres for further
check ups and mammography or scinti-mammography.
My greatest wish for the program is to provide organised training of female health
workers, female health visitors, nurses, and other women health care providers who are
licensed (e.g., homeopathic female doctors, traditional or eastern medicine health
providers) to work, but lack adequate training and skills. It has always been my dream to
initiate and establish an institution that could provide basic and recent training to health
professionals, especially paramedics.
I have reduced my expenses, forgone all leisure pastimes and have not traveled overseas
for the last eight years. I now have most of the required training materials. I have
gradually purchased a computer, printer, scanner, and digital web camera entirely from
my personal income. Towards this end, I have devised short courses for training and
ways of examining candidates who complete training.
What further help is needed?
We are looking for collaboration with individuals and organizations that could be of help.
We are trying our best to address women's health problems and some of its contributing
factors. We intend to train a lot of female school teachers and married women in personal
hygiene, safe motherhood, hazards of STDS and their prevention, and emergency family
planning .The most important of all is the training of traditional birth attendants as most
women here still prefer them.
Unfortunately, we are unable to do much to address the most aggravating factors,
unemployment and poverty. We intend to help transform women's lives with all possible
support including provision of small items of help in the form of paying off their bills for
repairing of sewing machines, small accessories and motors for sewing machines and
small financial aid to start work. We also want to arrange healthy competition among
female artisans to improve the level of their skills and to help them find suitable work.

source:www.mejfm.com

SITUATIONAL ANALYSIS OF WOMEN IN PAKISTAN —AN OVERVIEW

Introduction
The status of women in Pakistan is not homogenous because of the interconnection of gender
with other forms of exclusion in the society. There is considerable diversity in the status of women
across classes, regions, and the rural/urban divide due to uneven socioeconomic development and the
impact of tribal, feudal, and capitalist social formations on women’s lives. However, women’s
situation vis-à-vis men is one of systemic subordination, determined by the forces of patriarchy across
classes, regions, and the rural/urban divide.
Gender is one of the organizing principles of Pakistani society. Patriarchal values embedded
in local traditions and culture predetermine the social value of gender. An artificial divide between
production and reproduction, created by the ideology of sexual division of labor, has placed women in
reproductive roles as mothers and wives in the private arena of home and men in a productive role as
breadwinners in the public arena. This has led to a low level of resource investment in women by the
family and the State. Thus, low investment in women’s human capital, compounded by the ideology
of purdah (literally “veiled”), negative social biases, and cultural practices; the concept of honor
linked with women’s sexuality; restrictions on women’s mobility; and the internalization of
patriarchy by women themselves, becomes, the basis for gender discrimination and disparities in all
spheres of life.
Demographic Background
Pakistan is a federation of four provinces conjoined with the federal capital area, the
Federally Administered Tribal Areas (FATA), the Federally Administered Northern Areas (FANA),
and Azad Jammu and Kashmir. According to the census conducted in March 1998, the total
population of the country is 130.6 million with an annual growth rate of 2.6 percent. About 55.6
percent of this population is in Punjab, 23 percent in Sindh, 13.4 percent in the North West Frontier
Province (NWFP), 5 percent in Balochistan, 2.4 percent in FATA, and 0.6 percent in Islamabad.
Women form 48 percent of the total population and 52 percent are men. The population of women
has increased slightly more than the population of men. The latest intercensal average growth rate per
annum is estimated at 2.6 percent for women and 2.5 percent for men during 1981–1998.
According to the 1998 census data, 88 million people live in rural areas, whereas 42 million
live in urban areas. The data revealed that 45 percent of the population are below 15 years of age.
About 52 percent of adolescents are male and 48 percent are female. The dependency ratio is
approximately 87.1. On average, one person in the working age group population would have one
dependent in the year 1998.
The average age of women for marriage has increased from 17.9 years in 1951 to 20.8 years
in 1981. About 23 percent of females between the ages of 15 and 19 are married, compared with 5
percent of the male population in the same age group. A majority of women are married to their close
relatives, i.e., first and second cousins. Only 37 percent of married women are not related to their
spouses before marriage. The divorce rate in Pakistan is extremely low due to the social stigma
attached to it. In 1996–1997, according to official statistics, women-headed households
constituted only 7 percent of total households. The share of women-headed households is less in
urban areas as compared with rural areas.
2 Country Briefing Paper—Women in Pakistan
The Social and Cultural Context
The social and cultural context of Pakistani society is predominantly patriarchal. Men and
women are conceptually divided into two separate worlds. Home is defined as a woman’s legitimate
ideological and physical space, while a man dominates the world outside the home. The false ideological
demarcation between public and private, inside and outside worlds is maintained through the notion of
honor and institution of purdah in Pakistan. Since the notion of male honor and izzat (honor)1 is linked
with women's sexual behavior, their sexuality is considered a potential threat to the honor of the family.
Therefore, women’s mobility is strictly restricted and controlled through the system of purdah, sex
segregation, and violence against them.
In the given social context, Pakistani women lack social value and status because of negation
of their roles as producers and providers in all social roles. The preference for sons due to their
productive role dictates the allocation of household resources in their favor. Male members of the
family are given better education and are equipped with skills to compete for resources in the public
arena, while female members are imparted domestic skills to be good mothers and wives. Lack of
skills, limited opportunities in the job market, and social and cultural restrictions limit women’s
chances to compete for resources in the public arena. This situation has led to the social and economic
dependency of women that becomes the basis for male power over women in all social relationships.
However, the spread of patriarchy is not even. The nature and degree of women’s
oppression/subordination vary across classes, regions, and the rural/urban divide. Patriarchal
structures are relatively stronger in the rural and tribal setting where local customs establish male
authority and power over women’s lives. Women are exchanged, sold, and bought in marriages. They
are given limited opportunities to create choices for themselves in order to change the realities of their
lives. On the other hand, women belonging to the upper and middle classes have increasingly greater
access to education and employment opportunities and can assume greater control over their lives.
The most powerful aspect of social and cultural context is the internalization of patriarchal
norms by men and women. In learning to be a woman in the society, women internalize the
patriarchal ideology and play an instrumental role in transferring and recreating the gender ideology
through the process of socialization of their children. This aspect of women’s lives has been largely
ignored by the development initiatives in the country.
Education and Training
Despite the improvement in Pakistan’s literacy rate since its independence (1947), its overall
literacy rate of 45 percent (56.5 percent for males and 32.6 percent for females in 1998) is still behind
most of the countries in the region. The literacy rates may have risen generally; however, with the
increase in population, the number of illiterate Pakistanis has more than doubled since 1951, while the
number of illiterate women has tripled. Approximately 60 percent of the total population is illiterate,
and women form 60 percent of the illiterate population
Strong gender disparities exist in educational attainment between rural and urban areas and
among the provinces. In 1996–1997 the literacy rate in urban areas was 58.3 percent while in rural
areas it was 28.3 percent, and only 12 percent among rural women. There are also considerable
inequalities in literacy rates among the four provinces, especially disparities between men and women
(Table 1).
1 “Honor” can be interpreted in various ways but generally refers to women’s purity and modesty.
Situational Analysis of Women in Pakistan 3
Table 1: Literacy Rate in Provinces by Gender
(percent)
Punjab Sindh NWFP Balochistan Pakistan
Year Male Female Male Female Male Female Male Female Male Female Total
1975 31.6 12.6 39.3 20.0 24.1 5.3 15.0 4.2 31.8 13.0 23.2
1980 36.4 16.4 39.7 21.5 25.7 6.4 15.2 4.3 34.8 15.7 25.9
1985 40.8 18.2 43.2 22.4 30.5 7.1 17.9 4.9 38.9 17.0 28.4
1990 45.2 20.8 46.5 23.7 38.1 8.6 21.0 5.7 43.4 19.1 31.7
1995 50.0 24.9 51.6 25.8 47.3 12.0 25.3 6.6 48.7 22.5 36.1
Source: Social Policy and Development Centre, “Social Development in Pakistan, Annual Review, 1998,” p.130.
Despite the higher rate of female enrollment in 1998–1999 at the primary (4.6 percent male
and 8.0 percent female), secondary (1.2 percent male and 6.8 percent female), and high school levels
(7.4 percent male and 8.3 percent female), the gender gap in the literacy rate is widening in Pakistan.2
Of those without basic education opportunities, about 70 percent are girls. The primary school
enrollment rate for girls during 1996–1997 was estimated at about 66.6 percent of total female
population and 90.7 percent of males. This is primarily due to the high dropout rate among girls (50 percent).
The overall participation rate at primary stage is estimated at 77 percent (male 92 percent,
female 62 percent) during 1998–1999. At middle stage the participation rate is 51 percent (male 64
percent and female 37 percent), and at high stage it is estimated at 36 percent (45 percent male and 26
percent female). Gender disparities in educational attainment are even greater in the rural areas. Only
3 percent of rural 12-year-old girls continued in school, compared with 18 percent of boys. Fewer
than 1 percent of girls remained in school in the 14-year-old age group compared with 7 percent of
boys.3
At present less than 3 percent of the age group 17–23 have access to higher education.
Women in particular have limited opportunities to acquire higher education and attain professional or
technical degrees. This is due to the cultural prescription of gender roles and inadequate number of
vocational training and professional institutions for women. Out of 172 professional colleges in
1996–1997, only 10 exist exclusively for women. In the other 162 professional colleges, women can
get admission only against a reserved quota. The female enrollment in professional colleges was 48
against 100 boys in 1996–1997. Similarly, the gender ratio in 26 public sector universities, including
one for women, is 28.9 percent. In 1991–1992 the number of female polytechnic institutes was 12
with an enrollment of 1,676 women as compared with 40 male polytechnics with an enrollment of
21,503. Of the 12 female polytechnics, 8 are in Punjab, 3 in Sindh, and 1 in NWFP. Balochistan has
none. There are 12 female commercial institutions; all of them located in Punjab with an enrollment
of 1,493. This is small in comparison with 225 male institutions in all provinces with an enrollment of
20,527.
Interestingly, the educational achievements of female students are higher as compared with
male students at different levels of education.

source:www.adb.org

isasters, women's health, and conservative society: working in Pakistan with the Turkish Red Crescent following the South Asian Earthquake

In recent years, numerous catastrophic disasters caused by natural hazards directed worldwide attention to medical relief efforts. These events included the: (1) 2003 earthquake in Bam, Iran; (2) 2004 earthquake and tsunami in Southeast Asia; (3) Hurricanes Katrina and Rita in the southern United States in 2005; (4) 2005 south Asian earthquake; and (5) 2006 Indonesian volcanic eruption and earthquakes. Health disparities experienced by women during relief operations were a component of each of these events. This article focuses on the response of the Turkish Red Crescent Society's field hospital in northern Pakistan following the South Asian Earthquake of October 2005, and discusses how the international community has struggled to address women's health issues during international relief efforts. Furthermore, since many recent disasters occurred in culturally conservative South Asia and the local geologic activity indicates similar disaster-producing events are likely to continue, special emphasis is placed on response efforts. Lessons learned in Pakistan demonstrate how simple adjustments in community outreach, camp geography, staff distribution, and supplies can enhance the quality, delivery, and effectiveness of the care provided to women during international relief efforts.

source:www.researchgate.net

"Embarrassing" women's health issues

According to a recent article I read on WebMD, there are millions of women who don't want to talk about bodily conditions and issues that are considered shameful or embarrassing--this includes stuff like frequent urination, excessive sweating, gas, and vaginal odor. It makes sense, considering that according to researchers, "toilet talk is followed by body odors, vaginal odors, and bad breath in terms of embarrassing women's health issues." But at the same time, doctors suggest that since effective treatment is often in reach, NOT talking
But keeping tight-lipped about these issues does a disservice, since many times an effective treatment is available, she tells WebMD. Here are the top six most embarrassing conditions facing women and why you should stay silent no more.

source:www.wellsphere.com

Comparison of Women's Reproductive Health in Pakistan and Indonesia

Abstract
Despite some progress, women in Indonesia and Pakistan continue to experience gender discrimination, gender-based violence and several preventable health problems. Researchers and activists from the universities of Jakarta and Karachi have been networking with their counterparts at the Memorial University, Newfoundland, Canada, on these issues. They believe that women's subordination in the two countries is linked to their reproductive lives as controlled by the family in the context of a patriarchal interpretation of Islam. In this project, multidisciplinary teams based at the two universities will compile and analyze narrative materials (life stories) from two or three generations of women in 10 families in each country. The researchers will receive training and support in this form of qualitative research from the Women's Studies Program at Memorial University. Project outputs will include specific suggestions for legal reform in the area of reproductive and marriage rights in the two countries, and educational materials for activists and non-governmental organizations (NGOs).

Post-Project Summary
Both the Indonesian and the Pakistani team received thorough training in qualitative research methods and the ethical procedures followed by Canadian researchers. Together, the three teams modified and refined the original data collection and analytic procedures to fit the two national contexts. All three teams adopted and became skilled in the use of NVivo, a sophisticated qualitative analysis software. Indeed, the developer of NVivo, Dr Lyn Richards, became interested in the project and invited the project leader to be keynote speaker at the Qualitative Data Research-QSR annual conference and personally supported the team in the analysis. The Pakistani team collected 50 life stories from women in two distinct regions and included eight three-generation families. The Indonesian team collected 27 life stories from women in 10 families, including seven three-generation families, in five distinct regions. Interviews were conducted in the local language, and the data were transcribed into the main languages of each country (Indonesian and Urdu). English summaries of each interview were prepared and circulated to the three teams.

The project was unique in that it approached women as social, cultural and religious beings, rather than simply physical entities. In general, both the Indonesian and the Pakistani teams found a close relationship between poverty - including poor housing and hygiene - and poor reproductive health. They were able to highlight particular forms of health problems - violence, frequent childbearing, circumcision (Indonesia) and forced marriage (especially in Pakistan). They highlighted the close and often adverse connection between religious and cultural beliefs, and women's health. They also noted that since the inception of the project, the situation for women in both countries has deteriorated as a result of the rising influence of fundamentalist ideas accompanied by increased violence against women and, especially in Indonesia, growth of regulations contrary to women's human rights.

Both teams produced presentations and publications that emphasis women's human rights in the area of reproductive health and specific measures to help poor women in particular. For example, the Indonesian team produced two comic-strip books entitled Talking about Body and Sexuality : Pictorial Stories for Adolescents and Parents, by Kristi Poerwandari and Atas Hendartini Habsjah, and Reproductive Health and Rights of Women : Pictorial Stories of Empowerment, by Anita Rahman. These were launched at a number of local events. The Pakistan team held community meetings in two areas to report back on their research findings and discuss priority needs. As a result, team members now accompany women to hospital and clinic appointments, and a team of young women have been locally recruited for a health awareness program. The team also prepared a report for a local newspaper on the varieties of local marriage patterns and a handbook on marriage rights in the local language. Both teams incorporated their findings into curriculum materials and courses at their respective institutions and continued to do so after the end of the project. A full list of community educational materials, academic outputs and conference presentations appears in the final report.

Both teams endeavored to contribute directly to policy formulation in the two countries. The Pakistani team completed a report on the representation of women and gender issues in government-run school textbooks and sent the report to the Department of Education along with their suggestions and recommendations. They also presented a report on improving women's reproductive health in Pakistan at a workshop for policymakers and academics in September 2006. The Indonesian team focused on attracting government officials to their seminars and presentations. They also worked with a network to oppose trafficking in women and launched two books on the 20th anniversary celebrations of Kajian Wa.

source:www.idrc.ca

The Church of Pakistan (United)

Women's issues and concerns
Ignorance about women rights and issues
Patriarchy - specified stereotypes roles designed for women
Poverty and lack of economic opportunities
Patriarchy and stereotypes discriminatory norms and attitudes
Discriminatory laws and policies
Difficulty in getting judicial redress
Biased and discriminatory attitude of law enforcing agencies
Violence manifested in extreme forms such as honour killing, rape, mutilation of body parts shown in increasing incidents of violence against women
Education and health indicators are unsatisfactory
Harassment at workplace and in transports facility
No recognition of women's work, especially in sub sectors of economy
Trafficking in persons
Lack of implementing mechanisms and political commitment on Government's part to ensure women's rights.
Ordination of women
The Church's constitution is silent on this matter
Activities related to MDGs and Beijing Platform for Action
Run by Women's Desk: Feminism, Women Rights and Activism Training Program for Clergy wives; Women's Health Concerns project.

source:iawn.anglicancommunion.org

UNICEF brings community health care to quake-hit Pakistan

he village of Ghorisadan is tucked away in a hidden valley in the Pakistan-controlled part of Kashmir. The earthquake did not spare a single home. Now residents manage with what little they have – in very poor conditions. Some are trying to patch together temporary shelters out of broken wood they find in the rubble.

Gulhab is a grandfather to 15 children. He once had four houses for his extended family. Now he has nothing. But the family has been so focused on survival they have not had time to come to terms with the personal tragedy.

“Things have been very difficult. Some of our children were injured – and some died. Then right after the earthquake it rained – and we didn’t know what to do,” says Gulhab.

One of the things Gulhab and his family need most is health care. UNICEF and a local partner, the National Rural Support Programme, are sending female healthcare teams into Ghorisadan. These women have been sent to Islamabad for special training in health issues and now they are able to offer Gulhab the help he needs.


© UNICEF Pakistan/2005/Zaidi
Faisa providing first aid to an injured girl at Ghorisadan village of Muzaffrabad.
Faisa Parveez is a community health care worker. “We go to people’s homes and we tell them about health and hygiene, so they can keep clean and prevent illness,” she says. “People here are affected by the earthquake. For example they don’t have proper toilets so we have to advise them how to build them. If their children are sick then we give first aid on the spot and refer them to hospital if necessary.”

Faisa and her team travel on foot so they can reach inaccessible areas, where people need help the most. UNICEF supplies Faisa with basic medical supplies such as painkillers, rehydration salts, bandages and antiseptic creams.

The hardship of living outdoors in winter means people are more likely to fall ill. They often don’t have the resources to maintain even basic standards of health and hygiene. Small wounds become easily infected and immediate care is vital to avoid further health problems. And just as important to people like Gulhab is the knowledge that someone in the community cares enough to make a difference – on yet another difficult day.

source:www.unicef.org

www.mapsofworld.com

Breast cancer is the second most common type of cancer after lung cancer in Pakistan and ranked first in the Pakistani women. There is a significant increase in the number of cases in Pakistan has since the 1970s, partly due to the modern lifestyles in the Upper class.
The main cause of breast cancer is still unknown but different factors can become the cause. The risk factors that can trigger the disease are sex, age, childbearing, hormones, a high-fat diet, alcohol intake, obesity, and environmental factors such as tobacco use and radiation. Hereditary factors play a role, but research is still on its way to find the cause of breast cancer. In the last few years, the death rate graph declines due to availability of the most advanced surgical and medical techniques.
A typical sort of lump is the first apparent symptom of breast cancer. This lump appears quite different from the surrounding breast tissue. This lump is palpable by hand and can be visualized by mammogram. This lump can be found in the breast, in the armpit or under the collar bone. Other apparent indications of breast cancer are changes in breast size or shape, skin dimpling, nipple inversion, or spontaneous any sort of discharge. These all appear along with each other or single finding will leads to diagnosis. Pain may or may not associate any symptom.
If the lump gets infected due to any reason then there is pain, redness and swelling throughout the breast and the skin appears like an orange peel. In advance stages of the disease it can spread to different organs like bone, liver, lung and brain.
Self examination or by the doctor can simply help in finding the lump. But all lumps are not always cancerous. To rule out the danger different screening methods had been in use. X-ray mammography, MRI and CT scan can help in localizing the lesion.
Different laboratory investigations can help in grading the stage of the breast cancer. After localizing the lesion and accessing the stage of the disease surgery is the first line of treatment followed by treatment including radiation therapy, chemotherapy, hormone therapy, and immune therapy. The treatment is according the stage of the disease.
Interstitial laser thermotherapy is nowadays an innovative method for the treatment of breast cancer with minimal side effects reported so far. It is less invasive and surgery is not required in this method for removing the lump, and survival of the patient during intermediate follow up is good.
Radiation treatment after surgery can reduce the risk of recurrence when delivered in the correct dose. So patients are divided in low risk patients and high risk patients, and different treatment plans are according to the stage of the disease.During treatment patient immune system is highly compromised so immune therapy is required.
There are different factors which can determine the life expectancy of the patient with breast cancer that is staging, tumor size and location, grade, and the spread of the disease, recurrence of the disease, and age of patient. Younger women do have a poorer life expectancy then older one.

source:Breast cancer is the second most common type of cancer after lung cancer in Pakistan and ranked first in the Pakistani women. There is a significant increase in the number of cases in Pakistan has since the 1970s, partly due to the modern lifestyles in the Upper class.
The main cause of breast cancer is still unknown but different factors can become the cause. The risk factors that can trigger the disease are sex, age, childbearing, hormones, a high-fat diet, alcohol intake, obesity, and environmental factors such as tobacco use and radiation. Hereditary factors play a role, but research is still on its way to find the cause of breast cancer. In the last few years, the death rate graph declines due to availability of the most advanced surgical and medical techniques.
A typical sort of lump is the first apparent symptom of breast cancer. This lump appears quite different from the surrounding breast tissue. This lump is palpable by hand and can be visualized by mammogram. This lump can be found in the breast, in the armpit or under the collar bone. Other apparent indications of breast cancer are changes in breast size or shape, skin dimpling, nipple inversion, or spontaneous any sort of discharge. These all appear along with each other or single finding will leads to diagnosis. Pain may or may not associate any symptom.
If the lump gets infected due to any reason then there is pain, redness and swelling throughout the breast and the skin appears like an orange peel. In advance stages of the disease it can spread to different organs like bone, liver, lung and brain.
Self examination or by the doctor can simply help in finding the lump. But all lumps are not always cancerous. To rule out the danger different screening methods had been in use. X-ray mammography, MRI and CT scan can help in localizing the lesion.
Different laboratory investigations can help in grading the stage of the breast cancer. After localizing the lesion and accessing the stage of the disease surgery is the first line of treatment followed by treatment including radiation therapy, chemotherapy, hormone therapy, and immune therapy. The treatment is according the stage of the disease.
Interstitial laser thermotherapy is nowadays an innovative method for the treatment of breast cancer with minimal side effects reported so far. It is less invasive and surgery is not required in this method for removing the lump, and survival of the patient during intermediate follow up is good.
Radiation treatment after surgery can reduce the risk of recurrence when delivered in the correct dose. So patients are divided in low risk patients and high risk patients, and different treatment plans are according to the stage of the disease.During treatment patient immune system is highly compromised so immune therapy is required.
There are different factors which can determine the life expectancy of the patient with breast cancer that is staging, tumor size and location, grade, and the spread of the disease, recurrence of the disease, and age of patient. Younger women do have a poorer life expectancy then older one.
Breast cancer is the second most common type of cancer after lung cancer in Pakistan and ranked first in the Pakistani women. There is a significant increase in the number of cases in Pakistan has since the 1970s, partly due to the modern lifestyles in the Upper class.
The main cause of breast cancer is still unknown but different factors can become the cause. The risk factors that can trigger the disease are sex, age, childbearing, hormones, a high-fat diet, alcohol intake, obesity, and environmental factors such as tobacco use and radiation. Hereditary factors play a role, but research is still on its way to find the cause of breast cancer. In the last few years, the death rate graph declines due to availability of the most advanced surgical and medical techniques.
A typical sort of lump is the first apparent symptom of breast cancer. This lump appears quite different from the surrounding breast tissue. This lump is palpable by hand and can be visualized by mammogram. This lump can be found in the breast, in the armpit or under the collar bone. Other apparent indications of breast cancer are changes in breast size or shape, skin dimpling, nipple inversion, or spontaneous any sort of discharge. These all appear along with each other or single finding will leads to diagnosis. Pain may or may not associate any symptom.
If the lump gets infected due to any reason then there is pain, redness and swelling throughout the breast and the skin appears like an orange peel. In advance stages of the disease it can spread to different organs like bone, liver, lung and brain.
Self examination or by the doctor can simply help in finding the lump. But all lumps are not always cancerous. To rule out the danger different screening methods had been in use. X-ray mammography, MRI and CT scan can help in localizing the lesion.
Different laboratory investigations can help in grading the stage of the breast cancer. After localizing the lesion and accessing the stage of the disease surgery is the first line of treatment followed by treatment including radiation therapy, chemotherapy, hormone therapy, and immune therapy. The treatment is according the stage of the disease.
Interstitial laser thermotherapy is nowadays an innovative method for the treatment of breast cancer with minimal side effects reported so far. It is less invasive and surgery is not required in this method for removing the lump, and survival of the patient during intermediate follow up is good.
Radiation treatment after surgery can reduce the risk of recurrence when delivered in the correct dose. So patients are divided in low risk patients and high risk patients, and different treatment plans are according to the stage of the disease.During treatment patient immune system is highly compromised so immune therapy is required.
There are different factors which can determine the life expectancy of the patient with breast cancer that is staging, tumor size and location, grade, and the spread of the disease, recurrence of the disease, and age of patient. Younger women do have a poorer life expectancy then older one.

source:c/women-health/breast-cancer.php

Women's Health in Pakistan

Women's Health in Pakistan has improved a lot since organizations like Blue Vein have taken the initiative to make things better. Blue Vein is a women's organization that has been doing a laudable job in improving the women's health care aid in Pakistan. Apart from the numerous health conferences, the work it has done for breast cancer patients is the most exemplary among all.

Women's health in Pakistan is more than just an issue of under development in the country, an issue that includes the social norms and constructs that have for long kept women in the shadows. The maternity issues in the country are a major cause for the death of both mother and children during the time of pregnancy. It is the rural areas in Pakistan, which still has to go a long way in securing a healthy life for the women. The primary factors of women's death in the rural areas are negligence, ignorance regarding health and diseases, lack of proper medical infrastructure.

Several projects have gone on floor to alleviate women's health in Pakistan and reach out medical aid to women in regions and communities, where women suffer due to either negligence or lack of health care system. Major works are being done to improve in the fields of pregnancy care, sexually transmitted diseases, digestive disorders, pneumonia and tuberculosis.

source:Women's Health in Pakistan has improved a lot since organizations like Blue Vein have taken the initiative to make things better. Blue Vein is a women's organization that has been doing a laudable job in improving the women's health care aid in Pakistan. Apart from the numerous health conferences, the work it has done for breast cancer patients is the most exemplary among all.

Women's health in Pakistan is more than just an issue of under development in the country, an issue that includes the social norms and constructs that have for long kept women in the shadows. The maternity issues in the country are a major cause for the death of both mother and children during the time of pregnancy. It is the rural areas in Pakistan, which still has to go a long way in securing a healthy life for the women. The primary factors of women's death in the rural areas are negligence, ignorance regarding health and diseases, lack of proper medical infrastructure.

Several projects have gone on floor to alleviate women's health in Pakistan and reach out medical aid to women in regions and communities, where women suffer due to either negligence or lack of health care system. Major works are being done to improve in the fields of pregnancy care, sexually transmitted diseases, digestive disorders, pneumonia and tuberculosis.

source:www.mapsofworld.com

Women health workers: improving eye care in Pakistan

In Pakistan, female health workers (known locally as a ‘lady health workers’) have formed the backbone of the primary health care system for the past fifteen years.

These women are members of the communities they serve and are responsible for 150–200 households (around 1,000 people) each. They provide primary health care with a focus on reproductive health and family planning.

During the day, lady health workers visit women at their homes; in the evenings, community members who need help go to their local lady health worker’s home (known as the ‘health house’) for health advice and basic care, including first aid.

Using women in this role is very helpful in a country such as Pakistan, where direct interaction between women and men is not encouraged. When a woman in Pakistan wants to consult a male health worker, one of her male family members is expected to accompany her. As male family members often have to work, this can make it difficult for women to make use of eye care and other health services. Lady health workers have the advantage of being able to visit women in their homes, even when male family members are at work.

‘There has recently been a greater emphasis on eye care in the training of lady health workers’

Eye care training
Although eye care has been included in lady health workers’ responsibilities since the beginning, it has not been a priority. Thanks to the renewed commitment1 to eye care by Pakistan’s national government in recent years, however, there has recently been a greater emphasis on eye care in the training of lady health workers.

Lady health workers undergo three months of classroom training in primary health care, followed by field work lasting twelve months.

In the classroom, lady health workers receive between three and five days’ training in primary eye care. Although the time allotted to eye care has not increased, the training has recently become more in depth and a wider range of eye conditions are covered.

During their year of field work, lady health workers interact with communities who have eye problems; they also receive one or two additional days’ hands-on training in community eye care while in the field. The aim is for them to better understand common community eye health problems such as foreign body injuries, cataract, conjunctivitis, and trachoma. They also learn to perform vision screening and talk to community members about health and hygiene practices.

Until recently, training had been provided by ophthalmologists based in district community eye care programmes. In 2007, however, Sightsavers International started a national programme to develop master trainers within the National Programme of Family Planning and Primary Health Care (the programme responsible for lady health workers); these master trainers now conduct all training of lady health workers in Pakistan. A training manual in the local Urdu language has been developed in consultation with all parties and was approved by the national eye health committee.

On completion of their primary eye care training, lady health workers are able to perform basic vision assessments (they are given E charts to use); they are also able to deal with conjunctivitis and foreign body injuries. They can screen patients for cataract, trachoma, low vision, and childhood blindness and when necessary they refer community members to nearby eye care services.

Impact
In the Federally Administered Tribal Areas (FATA), where the new eye care curriculum was piloted and where it had been taught for five consecutive years (2001–2005), we found that lady health workers dealt with more than three times as many eye patients as colleagues in other provinces who had not yet received the training. The programme will be evaluated on a national level in November 2009.

source:www.cehjournal.org

Women's mental health in Pakistan

ABSTRACT

In Pakistan, societal attitudes and norms, as well as cultural practices (Karo Kari, exchange marriages, dowry, etc.), play a vital role in women's mental health. The religious and ethnic conflicts, along with the dehumanizing attitudes towards women, the extended family system, role of in-laws in daily lives of women, represent major issues and stressors. Such practices in Pakistan have created the extreme marginalisation of women in numerous spheres of life, which has had an adverse psychological impact. Violence against women has become one of the acceptable means whereby men exercise their culturally constructed right to control women. Still, compared to other South Asian countries, Pakistani women are relatively better off than their counterparts.
Keywords: Pakistan, women's mental health, cultural practices, honor-killing, stove-burns, violence
Other Sections▼

The women's movement in Pakistan in the last 50 years has been largely class bound. Its front line marchers voiced their concerns about issues mainly related to the urban-middle class woman. It is only in the last few years that rural women's issues like 'Karo Kari' (honour killing) and rape have been brought to light. Feudal/tribal laws of disinheritance, forced marriages and violence against women (acid-throwing, stove-burning homicide and nose-cutting) in the name of honour are being condemned by non-governmental organizations and human rights activists in the cities. Still a vast majority of the women in the rural areas and urban slums are unaware of the development debates.
The urban Pakistani women in many aspects are almost at par with the women of developed countries. In the rural scenario, the picture is entirely different. It is archaic, brutal and clearly oppressive. These trends often seep into the urban lives of women through migratory movements of rural population, which has yet to adjust to urban ways.
At the societal level, restricted mobility for women affects their education and work/job opportunities. This adds to the already fewer educational facilities for women. Sexual harassment at home, at work and in the society has reached its peak. Lack of awareness or denial of its existence adds to further confine women to the sanctity of their homes. Violence against women further adds to restriction of mobility and pursuance of education and job, thereby lowering prospects of women's empowerment in society.
At the family level, birth of a baby boy is rejoiced and celebrated, while a baby girl is mourned and is a source of guilt and despair in many families. Boys are given priority over girls for better food, care and education. Subservient behaviour is promoted in females. Early marriage (child-brides), Watta Satta (exchange marriages), dowry and Walwar (bride price) are common. Divorcees and widows are isolated and considered 'bad omens', being victims of both male and female rejection especially in villages. Marriage quite often leads to wife-battering, conflict with spouse, conflict with in-laws, dowry deaths, stove burns, suicide/homicide and acid burns to disfigure a woman in revenge.
Other Sections▼
VIOLENCE AGAINST WOMEN
In Pakistan, there are cultural institutions, beliefs and practices that undermine women's autonomy and contribute to gender-based violence. Marriage practices can disadvantage women, especially when customs such as dowry and bride's price, Watta Satta and marriage to the Quran (a custom in Sindh where girls remain unmarried like nuns to retain family property in the family) exist. In recent years dowry has become the expected part of marriage. This increasing demand for dowry, both before and after marriage, can escalate into harassment, physical violence and emotional abuse. In extreme cases homicide or "stove-burns" and suicides can provide husbands an opportunity to pursue another marriage and consequently more dowry.
Women are confined to abusive relationships and lack the ability to escape their captors due to social and cultural pressures. Parents do not encourage their daughters to return home for fear of being stigmatized as a divorcee, which tantamount to being a social pariah. Moreover, if a woman leaves her husband, her parents have to repay him to compensate his loss. Cultural attitudes towards female chastity and male honour serve to justify violence against women.
Violence against women is very common in Pakistan. The violation of women's rights, the discrimination and injustice are obvious in many cases. A United Nations research study (1) found that 50% of the women in Pakistan are physically battered and 90% are mentally and verbally abused by their men. A study by Women's Division on "Battered Housewives in Pakistan" (2) reveals that domestic violence takes place in approximately 80% of the households. More recently the Human Rights Commission report (3) states that 400 cases of domestic violence are reported each year and half of the victims die.
In Balochistan and Sindh provinces, Karo Kari is practiced openly. A woman suspected of immorality is declared a Kari while the Karo is a man declared to be her lover. A woman suspected of adultery or infidelity is liable to face the death penalty at the hands of her husband or in-laws. Usually the killer goes scot-free as he is regarded to have committed the crime in order to retrieve the lost family honour, which a woman is expected to uphold at all costs.
Watta Satta is also a tradition in many families in Punjab and Sindh, whereby a girl is married off to her sister-in-law's brother. Such an arrangement often leads to a complicated situation, since a woman ends up becoming a mere object of revenge in the instance that her brother mistreats or physically abuses his wife.
Sadistic urges may be satisfied by a man by totally humiliating as well as disfiguring his wife. Women who are victims of this particular form of violence are usually young and attractive.
Hundreds of women are disfigured or die of stove-burns every year. The victims are usually young married women and the aggressors include husbands and in-laws. The motive behind stove burning is to get rid of the woman and remarry for more dowries or have an heir for the family.
Battering or "domestic violence" or intimate partner abuse is generally part of the patterns of abusive behaviour and control rather than an isolated act of physical aggression. Partner abuse can take a variety of forms, including physical violence, assault such as slaps, kicks, hits and beatings, psychological abuse, constant belittling, intimidation, humiliation and coercive sex. It frequently can include controlling behavior such as isolating women from family and friends, monitoring her movements and restricting her access to resources. Physical violence in intimate relationship is almost always accompanied by psychological abuse and in one-third to one-half of cases by sexual abuse.
A woman's response to abuse is often limited by the options available to her. Women constantly cite reasons to remain in abusive relationship: fear of retribution, lack of other means of economic support, concern for the children, emotional dependence, lack of support from family and friends and the abiding hope that the husband may change one day. In Pakistan divorce continues to be a taboo and the fear of social stigma prevents women from reaching out for help. About 70% of abused women have never told anyone about the abuse.
The psychological consequences of abuse are more severe than its physical effects. The experience of abuse erodes women's self-esteem and puts them at a greater risk for a number of mental disorders like depression, post-traumatic stress disorder, suicide, alcohol and drug abuse.
Children who witness marital violence face increased risk for emotional and behavioural problems, including anxiety, depression, poor school performance, low self-esteem, nightmares and disobedience. Boys turn to drugs and girls become severely depressed and sometimes totally refuse to get married. Children under 12 years have learning, emotional and behavioural problems almost 6-7 times more compared to children of non-abusive parents.
Health care providers can play a key role. They must recognize victims of violence and help them by referring to legal aid, counsellors and non-governmental organizations. They can prevent serious conditions and fatal repercussions. However, many doctors/nurses do not ask women about the experience with violence and are not prepared to respond to the needs of the victims.
A variety of norms and beliefs are particularly powerful perpetrators of violence against women. These include the notions that men are inherently superior to women, that it is appropriate for men to discipline women, and that women's sexual behaviour is linked to male honour. Nobody is expected to intervene on behalf of the victim as such issues are considered private matters to be resolved by the immediate parties themselves.
Programs designed to change these beliefs must encourage people to discuss rather than antagonize or alienate them by appearing to 'demonize' men. A good tool is to encourage people to develop new norms by using techniques such as plays on TV and theatre.

PSYCHIATRIC ILLNESS IN PAKISTANI WOMEN
A large study at Jinnah Post Graduate Medical Center, Karachi back in early 1990s (4) showed that twice as many women as men sought psychiatric care and that most of these women were between 20s and mid 40s.
Another 5-year survey (1992-1996) at the University Psychiatry Department in Karachi (Agha Khan University/Hospital) (5) showed that out of 212 patients receiving psychotherapy, 65% were women, 72% being married. The consultation stimuli were conflict with spouse and in-laws. Interestingly, 50% of these women had no psychiatric diagnosis and were labeled as 'distressed women'. 28% of women suffered from depression or anxiety, 5-7% had personality or adjustment disorders and 17% had other disorders.
The 'distressed women' were aged between 20 to 45. Most of them had a bachelor's degree and had arranged marriage relationships for 4-25 years with 2-3 kids, and the majority worked outside home (running small business, teaching or unpaid charitable community work or involved in voluntary work). Their symptoms were palpitations, headaches, choking feelings, sinking heart, hearing weakness and numb feet.
A study on stress and psychological disorders in Hindukush mountains of North West Frontier Province of Pakistan (6) showed a prevalence of depression and anxiety of 46% in women compared to 15% in men.
A study on suicidal patients (7) showed that the majority of the patients were married women. The major source of suffer was conflict with husband (80%) and conflict with in-laws (43%).
A study of parasuicide in Pakistan (8) shows that most of the subjects were young adults (mean age 27-29 years). The sample showed predominance of females (185) compared to males (129), and the proportion of married women (33%) was higher than males (18%). Housewives (55%) and students (32%) represented the two largest groups among females. Most female subjects (80%) admitted problems with spouse.
A four-year survey of psychiatric outpatients at a private clinic in Karachi (9) found that two thirds of the patients were females and 60% of these females had a mood disorder. 70% of them were victims of violence (domestic violence, assault, sexual harassment and rape) and 80% had marital or family conflicts.
CONCLUSIONS
Pakistani women are relatively better off than their counterparts in other developing countries of South Asia. However, fundamental changes are required to improve their quality of life. It is imperative that constructive steps be taken to implement women friendly laws and opportunity be provided for cross-cultural learning. Strategies should be devised to enhance the status of women as useful members of the society. This should go a long way to improving the lives and mental health of these, hitherto "children of a lesser God".

source:www.ncbi.nlm.nih.gov

Unmarried Women becoming Pregnant

Country Context
Young women leaving home to work in factories present challenges to traditional patriarchal society. Moreover, cultural constraints obstruct women’s access to health and family planning services—for example, it is culturally taboo to provide contraception to unmarried women.

Considerable international donor and Pakistani government resources are being deployed toward combating HIV/AIDS, but additional resources are required to provide more holistic reproductive health solutions and outcomes that integrate HIV/AIDS awareness-raising and prevention activities as a part of a broader reproductive health program.

Unmet Health Needs of Female Factory Workers in Pakistan
Hepatitis B & C
Nutrition education
Hygiene and sanitation
Pre- and post-natal care
Family planning

Perspective
Context: Traditional Patriarchal Culture Challenged by Growing Economy
In Pakistan, the health issues are contextualized within a challenging geo-political climate coupled with enormous economic growth and traditional patriarchal society.

Women face particular challenges when they try to find their place in society. Men outnumber women in Pakistan – young girls have a higher fatality rate than young boys, because of discrimination against young girls with nutrition and health provisions.

An Ineffective Public Health System
Pakistan has health systems to protect their population on paper from their colonial legacy -- one of the best models on paper -- but implementation has generally failed, and particularly women are left untreated.

In Pakistan, many use the private sector instead, which is highly unregulated. Family planning, for example, is not very well organized.

Urbanization and the Karachi Garment Industry
The garment industry is very large in Pakistan -- Karachi in particular. Development is making rural villages more urban, but still 70 percent live in technically rural areas. Migration, particularly amongst young unmarried women, is driven by centralization in Karachi.

Wide scale migration by unmarried women greatly complicates the traditional social context -- they are stepping out of the home and not providing for their family in the way they are supposed to.

Women Factory Workers Suffer Discrimination, Harassment and Poor Health Services
In turn, the factories do not provide supportive environments for these workers. Discrimination is ripe -- most male workers are older and married, and sexual harassment is common. Women generally do not register complaints because they are too afraid.

If they get pregnant, abortion is not provided through the health service, which leads to great numbers of unsafe “backstreet” abortions.

Lack of Cultural Understanding Limits Health Knowledge & Services
The culture has no understanding of unmarried women becoming pregnant, which psychologically limits support for any of these issues amongst these women worker populations. For example, contraception is not allowed to be provided to unmarried women, so even if they were informed about needing protection, they wouldn’t be able to get any service in this area.

source:Context: Traditional Patriarchal Culture Challenged by Growing Economy
In Pakistan, the health issues are contextualized within a challenging geo-political climate coupled with enormous economic growth and traditional patriarchal society.

Women face particular challenges when they try to find their place in society. Men outnumber women in Pakistan – young girls have a higher fatality rate than young boys, because of discrimination against young girls with nutrition and health provisions.

An Ineffective Public Health System
Pakistan has health systems to protect their population on paper from their colonial legacy -- one of the best models on paper -- but implementation has generally failed, and particularly women are left untreated.

In Pakistan, many use the private sector instead, which is highly unregulated. Family planning, for example, is not very well organized.

Urbanization and the Karachi Garment Industry
The garment industry is very large in Pakistan -- Karachi in particular. Development is making rural villages more urban, but still 70 percent live in technically rural areas. Migration, particularly amongst young unmarried women, is driven by centralization in Karachi.

Wide scale migration by unmarried women greatly complicates the traditional social context -- they are stepping out of the home and not providing for their family in the way they are supposed to.

Women Factory Workers Suffer Discrimination, Harassment and Poor Health Services
In turn, the factories do not provide supportive environments for these workers. Discrimination is ripe -- most male workers are older and married, and sexual harassment is common. Women generally do not register complaints because they are too afraid.

If they get pregnant, abortion is not provided through the health service, which leads to great numbers of unsafe “backstreet” abortions.

Lack of Cultural Understanding Limits Health Knowledge & Services
The culture has no understanding of unmarried women becoming pregnant, which psychologically limits support for any of these issues amongst these women worker populations. For example, contraception is not allowed to be provided to unmarried women, so even if they were informed about needing protection, they wouldn’t be able to get any service in this area.

source:Context: Traditional Patriarchal Culture Challenged by Growing Economy
In Pakistan, the health issues are contextualized within a challenging geo-political climate coupled with enormous economic growth and traditional patriarchal society.

Women face particular challenges when they try to find their place in society. Men outnumber women in Pakistan – young girls have a higher fatality rate than young boys, because of discrimination against young girls with nutrition and health provisions.

An Ineffective Public Health System
Pakistan has health systems to protect their population on paper from their colonial legacy -- one of the best models on paper -- but implementation has generally failed, and particularly women are left untreated.

In Pakistan, many use the private sector instead, which is highly unregulated. Family planning, for example, is not very well organized.

Urbanization and the Karachi Garment Industry
The garment industry is very large in Pakistan -- Karachi in particular. Development is making rural villages more urban, but still 70 percent live in technically rural areas. Migration, particularly amongst young unmarried women, is driven by centralization in Karachi.

Wide scale migration by unmarried women greatly complicates the traditional social context -- they are stepping out of the home and not providing for their family in the way they are supposed to.

Women Factory Workers Suffer Discrimination, Harassment and Poor Health Services
In turn, the factories do not provide supportive environments for these workers. Discrimination is ripe -- most male workers are older and married, and sexual harassment is common. Women generally do not register complaints because they are too afraid.

If they get pregnant, abortion is not provided through the health service, which leads to great numbers of unsafe “backstreet” abortions.

Lack of Cultural Understanding Limits Health Knowledge & Services
The culture has no understanding of unmarried women becoming pregnant, which psychologically limits support for any of these issues amongst these women worker populations. For example, contraception is not allowed to be provided to unmarried women, so even if they were informed about needing protection, they wouldn’t be able to get any service in this area.

source:c/focus/pakistan.php

PAKISTAN: Health initiative offers hope to remote Tharparakar

Tharparakar District, Sindh Province, southern Pakistan, is one of the least developed districts in the country, but a new health initiative is providing a glimmer of hope to local people.

Poverty and lack of education here mean there are few health facilities and little awareness about women's health issues. Most babies are delivered at home by traditional birth attendants (TBAs), who also perform unsafe abortions when needed.

The district's government-run civil hospital, in Mithi, serves a population of over 900,000 people, and Abida Noreen is the first gynaecologist in the hospital trained to perform a Caesarian section.

Her job at the Mother and Child Health (MCH) centre is a result of a public-private partnership in which the government, the Thardeep Rural Development Programme (TRDP - a local NGO), and corporate donors hired her on a full-time basis in January 2008.

Also hired were a lady health visitor (LHV) and an anaesthesiologist. Some 15-20 Caesarians are performed in the hospital a month, and the surgery costs around Rs1,500 (US$19).

Low birth weights

Studies in the area suggest that in poor families 25-30 percent of babies are born under 2.5kg and usually die before their first birthday.

Government agencies have estimated that in rural areas of Tharparkar, the maternal mortality rate (MMR) is as high as 600 per 100,000 live births compared to a UNICEF estimate for the whole of Pakistan in 2006 of 320. The infant mortality rate for those aged under 12 months ranges from 80-100 per 1,000 live births, compared to the Pakistan-wide figure of 78. For related UNICEF statistics on Pakistan click here.


Photo: Sumaira Jajja/IRIN
Dr Mohni has brought a huge difference to the quality of healthcare TRDP head Sonu Khangarni says: "Given the low pay at state-run hospitals, trained staff refuse to work in places like Mithi, but due to this public-private partnership, the good pay attracted the right people. For the first time in 60 years we have this medical service in this area. It is a small step in the right direction."

Malnutrition, poor hygiene

Talking to IRIN about the health issues faced by women in this remote region, Mohni Gotam, another gynaecologist at the hospital, said: "Malnutrition and poor hygiene are major health issues with women, as urinary tract infections are very common here, followed by anaemia. Many times all that is needed is good hygiene and folic acid, along with a healthy diet."

However, LHVs said birth spacing and contraception were what women here needed help with. Sumera Mohammad Siddique, a young LHV at the MCH centre said: "We have women with six or seven children approaching us wanting to know about contraceptive methods. Yet when we tell them about condoms, they refuse [to use them], saying their husbands will not approve."

Saba (not her real name), another LHV said: "People here prefer terminating a pregnancy rather than opting for oral contraceptives or condoms. Women feel their husbands would think of them as 'loose women' if they told them to use condoms."

"Will of the gods"

Sitting on a bench waiting for her turn to see a specialist is heavily pregnant Nandni. In her 30s, she is pregnant with her ninth baby but this is the first time she has visited a doctor. "I gave birth to all my children at home as I cannot afford medicines and travel. But over the past three years, I have lost three babies and this time I did not want this to happen," she said. In tow is her 13-year-old daughter who was recently engaged and who will be married in a year's time.

When asked by IRIN if she knew that an early marriage might prove to be harmful to her daughter, she simply smiled, saying: "That's the will of the gods. If they want, she will go on and give birth to 10 healthy children and be there to look after them."

source:www.irinnews.org