Often it is tOO lAte
nikki van der gaag reports on family planning and maternal mortality in rural Pakistan.
barbara solangi
nasreen sits quietly in a corner while the other women from the kot Adu area in the Punjab talk. She looks in her twenties, but is tired and pale, and has a small child fretting and crying until he finally falls into an exhausted sleep. nasreen is poor, illiterate, and married very young. She says, miserably, that she has eight children. She doesn’t know very much about nutrition, hygiene, family planning or safety in childbirth. This could be putting her life at risk. officially, the maternal mortality rate in Pakistan is estimated to be 260 deaths for each 100,000 births. 52 But in every village i visit i am told of a woman who had died the previous day or the previous week. Talking to health workers, it seems likely that the numbers of women dying in childbirth, particularly but not only when there is a flood, is much higher than the statistics would seem to indicate. 53 Bilquis, a social worker in Thatta district, told me that she rarely visited a village where a woman had not died. The boys in the village take us out to show us how they construct a sling to carry pregnant women to hospital. They have to walk, or go in a donkey cart along rough and bumpy roads. not surprising, perhaps, that many women die on the way. There is another problem. Because the society is conservative and strictly controlled, any mention of sexual and reproductive health for adolescents and unmarried young people is impossible. for them, sexual and reproductive health services and information is simply unavailable. one report says: “There is in general a very low level of knowledge around family planning in southern Punjab. Unmarried adolescent girls have no access to information and even married adolescents and older women are largely unaware of modern 50
family planning methods. This also holds true for men and boys.”54 As a result, in rural Pakistan, knowledge about and access to family planning is low – only 30 per cent of married women between the ages of 15 and 49 use any form of contraception. 55 interestingly, in the aftermath of the floods of 2010, women and girls were often together in makeshift camps or schools which meant that there was an opportunity to access health and hygiene information. This included family planning advice and information about sexual and reproductive health and maternal health. 56 for example, the health visitor in the village of Jaday Wala outside muzaffagarh in the Punjab provided daily sessions on family planning for up to 30 women in the governmentrun camps. She thought that only one in ten of the women she talked to knew about modern methods of family planning before coming to the camp. But if only a few women a day like nasreen were able to start using contraception, in a two-month period this would mean that more than 400 women would have fewer babies; contributing to reducing pregnancy-related deaths and the perpetuation of cycles of mother-to-child poverty. one of the other positive things emerging from the training was that men became more relaxed with regard to their wives using family planning services. This too could have a long-term effect if the services continue to be available. But once the floods subsided, in most villages, things have reverted to their previous state as far as women like nasreen are concerned – no schools, no clinics, and little information on, or provision for health, and particularly sexual and reproductive health.