Odds against Pakistan’s girls & mothers-to-be

Zahida* from Mang Sharki village was 25 and eight-months pregnant when she went into early labour with her fifth child eight years ago. On her way to the nearest clinic in north-west Pakistan’s Balakot city, she died giving birth to an underweight baby girl. Lying on a jute ‘charpai’ (bed) in the back of a truck, Zahida was barely conscious. The vehicle had not even made it to the main road when she drew her last breath. Her baby also passed away on that cold night...

The one-hour journey to the clinic along a single, dirt and potholed track is what most mothers have to travel in order to give birth with medical help because there are no clinics or doctors at hand in these mountainous villages – that is why Zahida’s daughter Saleema* looks at the prospect of pregnancy and motherhood with so much fear.

Saleema, already married for one year, is just 14 years old.

Limited education, early marriage, premature pregnancy, difficult labours, poor diet and anemia and lack of primary health care all conspire against girls in Pakistan.

“Now after being pushed into a corner, as a victim of early marriage I fear to face the challenge of being pregnant as I don’t want to face the fate that my mother met eight years ago”, says Saleema.

“We still have the same poor diets, hardships, difficult terrain and pot-holed roads, where the nearest hospital facility is 100km away. The biggest fear is of leaving another orphan like me,” she adds.

Saleema recalls when she reached puberty and experienced her first menstrual cycle – something that shocked and horrified her because she had never been told what to expect: “I do not remember ever feeling happiness or joy. A sharp pain in my back emerged when I grew older [when Saleema reached puberty]. That was the start of my nightmare. With my mother not around, I was too shy to talk to anyone and in fact; I was scared to talk about it - that if I open my mouth about the symptoms I was facing, how they will react. Maybe it is a disease and they would throw me out of the village,” says Saleema.

“Whatever piece of cloth I could find; I would grab it to safeguard me from my problem. I started taking a bath everyday as it gave me mental relief from my condition. I used to wear dark clothes or stay indoors as much as possible. That nightmare used to come after two or three months and would stay for one month. I grew weak, unable to get out of bed. Constant pain in my back and legs became my only companion. Then one day I overheard my aunt speaking about the menstruation cycle for women. I was suddenly relieved that it is not a disease and it gave me some courage to talk to my aunt. When I told her that my menstruation goes for a month with excessive bleeding, she also was worried. After a week she got some medicine from some source, which did not help, but I kept quiet about the pain and misery,” she adds.

“We do not have a doctor or a trained lady health visitor in our village. Whatever we possibly thought, we tried for Saleema. Myself and other women in the village thought that if she married, her condition would probably improve. So we married Saleema with her paternal cousin just a year ago,” explains her aunt Khalida Bibi.

She continues, “If someone recovers from illness, it’s because of the prayers that God has listened to and we feel ourselves lucky to survive, otherwise there are no other alternatives. No primary health unit, medicine, doctor in our area, but more importantly is that there is no priority given to women”.

UNICEF’s State of the World’s Children 2009 report, which focuses on maternal and newborn health, confirms the fears of both Saleema and her aunt regarding pregnancy and childbirth.

One in 74 women will die of pregnancy-related causes in Pakistan, compared to just 1 in 4,800 in the United States or 1 in 13,300 in Australia, according to the report.

Antenatal care coverage in Pakistan, especially rural areas, is very low. Only 61% of pregnant women in Pakistan receive antenatal care, at least once during their pregnancy, whereas coverage in Nigeria is only just behind at 58%, according to the SOWC 2009 report.

Just 39% of women in Pakistan will have a skilled attendant to assist them during childbirth, compared to 33% in Niger; arguably the world’s poorest nation .

The same report indicates that Pakistan’s under-five mortality rating is 90 deaths to 1,000 live births, ranking Pakistan at 43 in the world – the same as Zimbabwe .

Factors contributing to high maternal mortality and infant mortality in Pakistan are both complex and very much interconnected. Averting maternal death helps safeguard the survival and health of newborns, says the SOWC 2009 report .

“Women are considered inferior and cannot live according to their wishes or give their consent at the time of marriage. They bear children until they reach menopause, work in the fields collecting wood, cutting and sizing according to needs, and cooking every day. They also do seasonal reaping of grass on slopes and cliff ledges for their domestic livestock to survive the harsh winters - all without safety equipment, putting their lives at risk,” her aunt adds.

Khalida Bibi has six children; three girls and three boys, with her two elder daughters married.

“My daughter’s youngest child is two years of age, whereas my youngest son is two-and-a-half years old. When we get married, we have babies until we are not capable of producing anymore (menopause). Sometimes I feel that my parents and their parents never asked the permission of their daughters. It may be because of this curse females face - continuous labour, fatigue, no voice and the ill medical state, it all kills us like a slow poison,” says Khalida Bibi

The three villages of Dana, Mang Sharki and Mang Garbi on three mountains in north-west Pakistan’s Kaghan valley, face each other, sharing almost the same threats and deprivation. Nutrition, education and health are ‘privileges’ of male members of society.

With no doctor, no infrastructure, especially roads, no means of reliable transport and limited education, the female population is living a life in the shadows – with a 1 in 74 chance of dying of pregnancy-related causes.

Yet recent estimates indicate that providing basic preventive and curative interventions for mothers and newborns in primary-health-care settings at pragmatic levels of coverage has the potential to reduce maternal and newborn deaths by 20–40 percent.

Life in these snow covered mountains looks very beautiful through the camera lens but very hard to bear through an open eye. Girls grow up in the shadows of poverty, discrimination and helplessness. They aren’t told what changes will take place in their bodies once they reach puberty and they can’t share their fears and questions with anyone.

“When I found out I was to get married, I was in a state of extreme fear and shock. And this fear became another nightmare when I was actually married. My husband is a student of 12th grade. I am very uncomfortable whenever he approaches me at night. My fear inside culminated into shear pain in my legs and a strange headache. I am unable to talk it out with him as he thinks that I am rejecting him. He is not a bad person, but somehow or other he never understands. All I do is to bathe a lot and say my prayers, which gives me some relief”, continued Saleema.

There are numerous stories like Saleema’s in every household. World Vision Pakistan’s Mother and Child Health (MCH) project has provided much-needed pre-natal and ante-natal care for mothers and their infants in four villages in the Kaghan Valley – including Mang Sharki, over the past two years.

The project benefitted a total of 30,000 individuals through direct healthcare or health-related activities. It provided 4,000 women with antenatal and postnatal care and some 20,000 children benefitted from health-related activities, with an average of five children per household. Some 8,000 women indirectly benefitted from the project through health education, etc.

In addition to providing direct healthcare, a female doctor, Community Mobilisers and advocacy staff all worked together to run ‘Health Days’ where women could come together to share their health problems and concerns. Finally, girls like Saleema had a safe space in which to tell their stories and get information.

However, in terms of addressing health issues and more fundamental issues like education for girls and early marriage in these rural communities, there is still a long way to go.

More than 1,000 villages dot the mountains of this sub-district – all requiring more health care staff – especially for pregnant women, mothers and infants, but also for informing all girls about reproductive health.

World Vision’s Mother and Child Health project has come to an end because its funds have been exhausted. World Vision needs US$100,000 a year in order to restart the programme so that other young mothers like Saleema have the opportunity to not only give birth safely, but to live a long and happy life with their children.

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*Name is changed due to confidentiality of the person and sensitivity of the issue.

Other statistics from SOWC report-

In 2006, research by the World Health Organisation recommended that countries should have an average of 2.28 health-care professionals per 1,000 population to achieve adequate coverage of skilled health personnel at delivery.