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Being a mother – How breastfeeding can save lives of Pakistan’s infants

breastfeeding pic
By Farahnaz Zahidi

August 7, 2016

The myth that just mother’s milk does not suffice has caught on, and this trend is an imminent danger to the lives of Pakistani infants

Her fifth child is due any day. Nazeer Bibi lives in a shanty part of Qayyumabad, Karachi, and has already decided that she will feed her baby formula milk.
“I work in three houses as a domestic help to support my family. I leave at 8 am after dropping my older children to school and return by 4 pm, and the baby will have to be at home. What option do I have? Besides, dabbay ka doodh (formula milk) makes babies healthier. I want my baby to be healthy like the babies in advertisements.”
Nazeer’s baby will be one of the 62 per cent Pakistani infants who are not exclusively breastfed. Only 38 per cent of infants under the age of six months are exclusively breastfed, according to the Pakistan Demographic and Health Survey (PDHS) 2012-13. The rates are the lowest in South Asia.
The myth that just mother’s milk does not suffice has caught on, and this trend is an imminent danger to the lives of Pakistani infants, a danger that is not talked about often enough. As the World Breastfeeding Week is celebrated globally from August 1-7, the conversation around breastfeeding needs to be more audible and frequent in Pakistan. But bringing up the topic inevitably initiates parallel discourse regarding how lives of infants are less safer till formula milk is promoted as a choice. “From tobacco, to sugar, to formula milk, the most vulnerable suffer when commercial interests collide with public health,” says an editorial in medical journal The Lancet.
“Formula milk should only be given when there is a medical reason for it,” says Dr Azra Ahsan, an expert in mother and child health. “The baby gets complete nutrition through breastfeeding. The mother passes on her protective antibodies to prevent common illnesses in the baby. As no water is required to prepare it, unlike how formula milk is prepared, the chances of diarrohea and vomiting are minimised.”
According to the World Health Organisation (WHO), breastfeeding has the potential to prevent about 800,000 under-five deaths per year globally if all children 0-23 months were optimally breastfed. Pakistan has one of the highest infant mortality rates in the region, all the more reason that breastfeeding must be encouraged, especially among the lower income strata.
The PDHS 2012-13 findings also show increase in bottle feeding rates in Pakistan.
“Babies who are born to mothers from the lower income strata are more at danger if they are not exclusively breastfed. The water these mothers use to prepare the formula is unhygienic, and the bottles are not sterilized. Also, formula milk is not cheap. Once they start the baby on it, they start diluting the milk over time so that the formula powder lasts longer; as a result, the baby becomes malnourished,” says Neha Mankani who works as a community health midwife at a hospital in Karachi.
According to the World Health Organisation (WHO), breastfeeding has the potential to prevent about 800,000 under-five deaths per year globally if all children 0-23 months were optimally breastfed.
Once the baby is started off on top feed, the unaffording or unaware mother, over time, starts substituting it with unboiled cow’s milk or low quality tea whitening milk powder which is unsuited for an infant. “We can try and convince the mothers but only till they are in the hospital. Also, Community Health Workers (CHWs) have no access to women who deliver at home,” says Mankani, adding that she and her colleagues try to convince mothers to breastfeed.
However, part of the problem could be that healthcare providers are not doing enough to raise awareness. “Healthcare professionals are the main culprits. Instead of advising new mothers to breastfeed, they help perpetuate the trend of using formula milk. They are given incentives by formula milk companies. Research shows that children delivered in hospitals are more frequently formula fed,” says Dr DS Akram, Founder, Health, Education & Literacy Programme (HELP).
The laws protecting the right of the infant to health and nutrition are there. Lawyer Summaiya Zaidi says that the primary focus of laws like the Protection of Breast-Feeding and Child Nutrition Ordinance 2002 is to protect the nutrition of the child and promote breastfeeding as a primary source of nutrition. After the devolution, each province developed its own Acts for the purpose.
“The Sindh 2013 Act stresses that manufacturing, advertising and sale of alternate sources of child nutrition cannot be promoted as better than mothers’ milk or even compared to it. This stresses the primacy of breast milk as the best source of nutrition for a growing baby, and only when the mother is unable to provide the same to her child should alternatives be made available. It basically controls the manufacture and advertising of child nutrition products by placing certain legal limits on promotion of the same,” says Zaidi.
Yet, the tussle between public health experts and forces of consumerism continue. Companies producing or distributing formula milk refused to give any statement regarding how they justify the tempting advertising campaigns.
At the 69th World Health Assembly earlier this year, a resolution welcomed WHO’s guidance on ending the inappropriate promotion of foods for infants and young children. The guidance states that in order to protect, promote and support breastfeeding, the marketing of “follow-up formula” and “growing-up milks should be regulated. This recommendation is in line with the International Code of Marketing of Breast-milk Substitutes.
“The laws are there, but the implementation is a distant dream. Formula companies continue to particularly tantalise urban markets,” says Dr Akram, adding that the government does not seem interested in this cause. Dr Akram and her team run the Baby-friendly Hospital Initiative (BFHI) of WHO and UNICEF successfully in Pakistan for a few years. “When external funding stopped, the government was not interested in investing in it,” she says, adding that companies that produce formula milk mainly target the urban market to tantalise consumers.
“For the poor population in rural areas, breastfeeding is mostly the only available option. The urban social landscape is more challenging when it comes to breastfeeding. More mothers are working mothers; more options for top feed are available here; more people can afford to buy formula milk. Awareness is needed in both rural and urban areas,” says Dr Sara Salman of WHO Sindh.
According to Mankani, despite trying to raise awareness, most mothers follow popular myths. “They feel the baby is healthier if fed formula, owing to the aggressive marketing of formula milk.”
The biggest challenge for exclusive breastfeeding is the perception that mothers are not producing enough milk and should supplement with formula because the baby cries, says Meredith Jackson-deGraffenried from Helen Keller International. “This perception is driven by the misunderstanding that if the mother is undernourished and poor, she must be incapable of adequately nourishing her baby.”
“We try to teach these women basics about expressing their own milk and how to store it. Mother’s milk stays fine for up to three days in a refrigerator, and up to six hours at room temperature. It’s an economical and healthier option. But myths are hard to fight,” says Mankani.
Despite proven benefits like the mother who breastfeeds return to her pre-pregnancy state much earlier, and the incidence of breast cancer in women who breastfeed being much lower, as Dr Ahsan says, the myths seem to be winning.
“Socially, breastfeeding proves a challenge as well. There are usually no crèche or nursing rooms at work. That’s one reason working mothers stop breastfeeding,” says Dr Ahsan.

Originally published here: http://tns.thenews.com.pk/mother/#.V6hsuPkrLIX

So who should talk to the 20-somethings about contraception?

Published: January 27, 2016

The world is realising that due to cultural norms, adolescents and young people often do not discuss contraception with their elders or family members. PHOTO AFP

They can curse in each other’s presence, break traffic signals in unison and smoke together, and they may at times act macho and show off their romantic escapades. But young men, like their elders, do not readily open up about reproductive issues. Parents or teachers do not discuss subjects of a sensitive nature with them. While it is the same with adolescent and young women, they are comparatively more open to confiding in each other and getting guidance.

But it seems the world may be in for a change in attitude. Young men, all over the world, are stepping up to take part in reproductive discourse.

One such young man is Hamza Moghari. He is still reeling from the long journey from Deir El-Balah in Gaza, Palestine, to Bali, Indonesia. And the reason why he is there is that he has the guts to talk to his peers about difficult subjects like contraceptive choices and reproductive health. Hamza has seen more violence and difficulty than he deserved to in his tender age of 22 years. Coming to the International Family Planning Conference (ICFP) 2016 is a dream come true for him.

“This is the first time I sat on an airplane. I nearly never came,” he says, sharing the long journey of how he first reached Jordan from his home in Gaza.

He explained that he was sent away and told to go back due to lack of a no objection document, but he stayed near the border and went back the next morning, and was finally let into Jordan from where he flew to Bali.

A tad bit shy by nature, he confesses that the most difficult subject to talk about with boys his age is sexuality. Yet it seems that the world is realising that due to cultural norms, adolescents and young people often do not discuss these issues with their elders or family members. With their own age group, if they feel safe enough, they can talk about the typically hushed topics too. Y-PEER, a youth network of young people from more than 700 non-profit organisations and government agencies in more than 50 countries initiated by the United Nations Fund for Population Activities (UNFPA), uses an integrated approach to work with young people on subjects like gender, contraception and reproductive health. This year the thrust of all the discussions at ICFP was how to involve youth in the process. Half of the world’s population today, which is over 3.5 billion people, is under 30, mostly living in developing countries. They need guidance on these matters and silence may not be feasible anymore.

“If you’re not on the table you’re on the menu. How do we bring the youth on the table to talk about family planning?”

This question was put forth by Katja Iversen, CEO of Women Deliver, at the ICFP.

Pakistan is currently the world’s seventh most populous nation, according to the registered number of Pakistani, 199,085,847 in July 2015, as per the CIA FactbookContraception is thus an important subject that should be included in the nation’s narrative at all levels. In Pakistan too, this working via youth strategy has found a foothold.

One such initiative is Chanan Development Association (CDA). What started as a small theatre group is now an organisation that is youth-led and works for the youth.

Muhammad Shahzad, the executive director, has in tow young leaders wherever he goes. At the ICFP, too, he is watching out for and introducing proudly bright young people from Pakistan. One of them is 24-year-old Qaisar Roonjha, who says working with and for people his age is something he just has to do. His organisation, WANG (Welfare Association for Young Generation), is youth-led, and its primary focus is to struggle for a fairer society. Important buzz words like Youth Development, Women Empowerment, Mother and Child Health, Young Girls Education, Gender justice, Peace Promotion, Youth Development and livelihood security are all highlighted on the WANG website. From Lasbela in the perilous province of Balochistan, Qaisar has come a long way.

“I have met at least 40,000 young people all over Pakistan in the last five years,” he says with pride.

He shares that the toughest subject to tackle while talking to young people in Pakistan is gender equality.

“They still seem ready to discuss contraception. At least the married ones do. But seeing women as equal partners is difficult,” adds Shahzad.

Qaisar, whose video was selected for a competition held by organisers of the ICFP, attended the high profile conference in Bali as a moderator.

Ayesha Memon, an MBA student and youth leader from Hyderabad, also won the same recognition for her video, and addressed groups of interested activists and experts at the ICFP.

“Young people need to come out of their boxes; we should not assume things can’t change.”

Sharaf Boborakhimov is no novice at engaging with his peers on some of the trickiest subjects, which especially boys never openly talk about. Originally hailing from Tajikistan, he currently lives in Sofia, Bulgaria. This graduate in International Economy joined Y-Peer in 2011.

“What we do is provide safe spaces to youth where they can talk about sensitive subjects to people their own age. The peer-to-peer methodology works in tackling these subjects. We choose each word very carefully. We have to memorise manuals to know what to say and what not to and how to approach a subject.”

He has a close eye on the Syrian crisis, has Syrian friends, and has worked in Jordan closely with Syrian refugees who have made the Zaatari Camp their permanent home.

“We specially trained couples so that they could go back in the camps and train others. The refugees are just like any other couple. All they want is peace. They are depressed and frustrated no doubt. But in them I see a vision and a hope for a better tomorrow. They need guidance about contraception too.”

Theatre-based peer education, in Sharaf’s view is most effective for youth, whether they are refugees or not, the same strategy Chanan begun with.

“Since 2009, we have recruited some 50,000 young people for Y-Peer who work with us to educate their peers in important matters like sexual and reproductive health rights and also contraception,” Shahzad shares, adding that Pakistan was the first country in Asia Pacific that introduced UNFPA’s Y-Peer program in the region in 2009.

They are working with youth across 135 districts spread all over Pakistan including its toughest regions. In Pakistan, 65 per cent of the population is under 29, and 40 per cent fall into the even narrower age bracket of 10 to 24 years, says Shahzad.

“A big focus of our work is to engage with policymakers,” he says, sharing that Chanan was part of the National Task Force of 2009 for youth policy development, and is hosting the National Secretariat for Y-Peer in Pakistan.

For Hamza, the journey started by working for a local Palestinian organisation called Palestinian Family Planning and Protection Association (PFPPA). He is studying to get a degree in nursing.

“There are two million people in Gaza. The blockade is continuing since two years. Aid and medical help is almost impossible. Unemployment in my people is 70 per cent; among the youth it is 55 per cent. The healthcare system is fragmented. Very few people are able to reach the government-run healthcare centres.”

“In shelters that he has worked in, two to three thousand people were staying in one school. That meant each classroom was housing at least 50 people. Men, women and children, all strangers for each other, crammed into one room. With no food and water at least for the initial days till help started trickling in. Do you think family planning is a priority for them on a hungry stomach?”

In difficult situations and at such a young age, to be taken seriously and sensitise people about contraception is an uphill task. But these young people have realised that their generation’s reproductive choices will shape future demographic trends. They are thus helping their peers make informed decisions.

Women in rural Pakistan champion the cause of population planning

By Farahnaz Zahidi Published: July 11, 2015

Benazir With the government lagging behind, women in villages of Pakistan are working for population planning. PHOTO COURTESY: SHIRKATGAH

KARACHI: Her father earns a meager Rs4000 a month as a gate keeper in the village school. Yet, this 18-year-old girl, whose biggest dream in life is to have her own computer, choses to do social work free of charge. “Anything that will help my people,” she says. She visits every home in the tiny village of Allan Chandio in district Shaheed Benazirabad, Sindh, convincing them to practice family planning (FP) and allowing their daughters to study so that they can make informed decisions about their lives. “I even visit my uncles,” says Benazir Chandio with a broad smile. She does this in a culture where issues like contraception are brushed under the carpet. “They say you are too young to be teaching us. I reply that if God has given me more awareness than you, then I have every reason to teach you.” Benazir, who has been given a well-deserved place in Shirkatgah’s “Building Momentum – Strengthening Champions” initiative, convinced two families to delay the weddings of their very young daughters. “Postponing those weddings for two years gave those girls some time to get ready for marriage and motherhood,” she says, and shares with pride that one of those girls recently gave birth to a baby girl at the right time. For women in her village, having anywhere between eight to 12 children is a norm. But she feels that with counseling, villagers are getting convinced to plan their families. Standing at number six among the world’s most populous nations, Pakistan needs more such girls. In absence of satisfactory performance from the government, the onus to cause a change has fallen on the civil society. Read: Addressing the baby boom: Women’s reproductive health an urgent issue Experts like Country Director Population Council Zeba Sathar express dissatisfaction over Pakistan’s success in FP. “Pakistan’s performance in lowering its fertility is indeed dismal; while we had some success in the 90s, the last 15 years have been a virtual standstill,” says Sathar. According to the Pakistan Economic Survey 2014-15, Pakistan’s estimated population is over 191.71 million. While there seems a definite decline in Pakistan’s population growth rate (1.49 per cent in 2014, according to CIA’s World Fact Book), there is much to be done. At the 2012 London Summit on Family Planning, Pakistan had committed to increase the contraceptive prevalence rate to 55 per cent by 2020. Five years short of 2020, the world looks on to see if the commitment will be honoured. “Pakistan’s pledge at the London Summit is an opportunity, perhaps the last, to actually ratchet up efforts, drum up the political will and redesign the programs to accelerate family planning in Pakistan,” says Sathar. Dr Azra Ahsan, technical consultant to the National committee for Maternal and Neonatal Health (NCMNH), says that health care providers need to be convinced first. “When they are not on board, how can we convince patients? What our medical students are taught is not relevant to ground realities. We know more about endoscopic and robotic surgeries, but our medical graduates don’t know about maternal health or public health policies.” Ahsan adds that every health care provider should be trained to guide patients in FP. “Why is it just the gynecologist’s job? Between being referred from one specialist to another, patients slip away,” says Ahsan, and suggests that The World Health Organization’s (WHO) medical eligibility criteria (MEC) wheel should be on every doctor’s table. “It is such a simple guide advising which contraceptive is advisable for whom.” Dr Farid Midhet, demographer and Country director Jhpiego, feels that one factor could be the general instability on many fronts in the country. “We are struggling with the same issues since the last two decades.” One thing that could work, according to Midhet, is integrating population planning into the public health system. Talking about unmet needs of contraceptives, he says that the use of traditional methods of contraception have gone up by ten per cent, citing the latest PDHS results. However, traditional methods in his opinion are not reliable enough. “A Population Council Pakistan research on Barriers to Contraceptive Use, 2013, shows that contrary to popular belief, neither religion nor male dominance are the main reasons for unmet need. Supply is the main factor here,” he says, adding that if supply is steady and is accompanied by counseling, use of contraceptives in Pakistan can go up by 50 per cent safely. Sharing research showing the gap between what women want and the four million unwanted and mistimed pregnancies that are happening annually, Sathar says, “Two million of these end up in abortions, which could be avoided by better family planning programs.” The aforementioned Population Council study confirms what most experts say – that Punjab is way ahead other provinces in terms of reaching developmental goals, including FP. “Punjab is the only province that may abide by its commitments in this regard. It is initiating the post-partum contraception program, which will be putting to use new technology,” says Midhet, adding that in comparison, Sindh faces more serious issues like lack of implementation of policies, corruption and shoddy governance. Read: One death too many: One death in childbirth every 37 minutes “The provinces are ready to play their role and have set ambitious goals for 2020,” says Sathar, expressing hope that the provincial governments now realize that they must set family planning as a priority. “While there are improvements in the budget lines for contraceptives (previously supplied by donors), funds and priority still lag behind.” Conflict and insecurity has affected more than just health initiatives, with mental illnesses on the rise in Pakistan, especially in women, says Dr Rukhsana Ansari from Indus Hospital, Karachi. “It has a close link with inflation and poverty. Too many children exacerbate women’s problems,” she says, adding that mothers from underprivileged backgrounds suffer from nutritional deficiencies, muscular and skeletal diseases and sleep deprivation. In turn, the children they give birth to are also malnourished. Mothers feel frustrated when they cannot go back to work because of their small children dependent on them, in situations where earning could alleviate their miseries. “If at all women chose to use contraception, the decision is not theirs. It is either the husband or the mother-in-law who decides.” Mehnaz 1 If the Lady Health Worker (LHW) program is re-focused on FP, it could yield results. Mehnaz is one such promising LHW. She has succeeded in convincing most households in the village of Kahazana Dheri, District Mardan, in Khyber-Pakhtunkhwa, to use contraceptives. “I can safely say that now at least half of the couples in our village are using contraception,” says the 36-years-old woman, another one of the Shirkatgah Champions. Yet, the obstacles are many. “Our area was devastated by the 2010 floods. Additionally, incidences of terrorism affect everything – when roads and bridges are blown off in bomb attacks, how will contraceptives reach small health facilities? People lose jobs in conflict areas. For an unemployed man, feeding his family becomes priority instead of buying contraceptives.” Published in The Express Tribune, July 11th, 2015. http://tribune.com.pk/story/918815/women-in-rural-pakistan-champion-the-cause-of-population-planning/

Senegal – A wonderful Slice of Africa

See Senegal through these photographs before you read this travel blog:
http://www.flickr.com/photos/farahnaz_zahidi/sets/72157629950698529/

Of eleven splendid suns
The crashing waves, the birds swimming in the air, humans scurrying around on their daily routines, everybody in their orbits. Tranquil. That’s Senegal
By Farahnaz Zahidi Moazzam

Pakistan has no embassy of Senegal. The visa processing takes months, if at all one gets it, that is. It’s an 11-hour flight from Dubai, that’s how far it is. And I must, must go there for a really important conference. Only, till the last day, I don’t know whether I will get the visa or not. Net search has told me that Senegal is sunny, beachy and hardcore Africa.

On the day I have to fly out, November 25, 2011, I reach Karachi airport with a fuzzy mind owing to the lack of sleep and simply too much going on in life. After a 3-hour layover at Dubai airport, a delightful surprise is in store —I have been upgraded to business class. I see that as a sign that the upcoming trip will be joyous. My seat is sandwiched between two nice gentlemen, one a Senegalese who is the same age as me but respectfully calls me “mama” just like our shopkeepers say baji or aunty. This is my first taste of friendly, amiable Senegalese people.

Senegal is 94 per cent Muslim. This is apparent when I see the tiny Dakar airport, antiquated, over-crowded with people returning home after Haj on packed flights. I hardly spot any computers. Everything is done manually. The visa-on-arrival and the long-awaited arrival of baggage takes hours! Finally out, I have my first chit-chat with the shuttle driver as we drive towards the hotel.

Pretty quaint little buildings, French architectural influences, a winding drive along an upscale road alongside the beach, and I reach the hotel. Ngor is the area, pretty, clean, with very little traffic. The same whiff of moisture-laden air that is typical of beach towns, but thankfully lacking the pollution of Karachi. I am in Dakar, the capital city of Senegal.

I get a room with a view, literally. Most of the hotels in Dakar are situated along the sea. Beautiful, clean beaches with abundant sea shells strewn along, not just in white but in dark ebony colour too.

Dakar is relaxed, as are the people. I can feel my inner pace slow down, a pleasant change after Karachi. The crashing waves, the birds swimming in the air, the breeze ruffling the leaves, humans scurrying around on their daily routines, everybody in their orbits. Tranquil. That’s Senegal.

One of the things you notice instantaneously in Senegal is the size of living beings (yes, I choose my words carefully here). The people are really tall. The birds are really big. Even the insects are bigger than the ones I see at home. And the birds are a treat for bird-watchers. Particularly the Senegal parrot is a sight to behold.

If anyone plans to go to Senegal, it is time they brush up their French, because English is rarely understood or spoken in this purely Francophone part of West Africa. By the end of my 11 days in Senegal, basic French started to make sense to me again, especially when spoken in an African accent. Influences of French remain on every aspect of culture, and continental cuisine is readily available, though local Senegalese food is known for its aromatic delicious flavour. Availability of halaal meat made life easier for me. Baobab is Africa’s popular fruit, and its milky juice is a refreshing welcome drink often served in Senegal. A popular main course specialty is Yassa chicken, which is grilled chicken served with sour spicy onion curry, and either steamed rice or plantains on the side. Seafood was always fresh, simply prepared and often served with assortments of cheese. Thiof fish was a personal favourite, fresh from the ocean, melting in the mouth.

Shopping in Senegal is a joy, simply because it is affordable for Pakistanis. In addition, this is a talented nation when it comes to arts and crafts which reflect their rich culture and many struggles. Street art in Senegal is breathtaking. Vendors on foot with amazing pieces of painting will come knock on your cab’s window. And you will be blown away by the vibrant colours, the finesse and the symbolism in the masterpieces these untrained artists churn out day after day. Craft pieces not to be missed include leather-bound boxes, bead and shell accessories, silver jewellery and baskets made of palm. If in Dakar, do visit the local Sandaga market. The sights, sounds and smells in this place gave me a true taste of Africa. But watch out for con artists and be ready to get followed around by persistent and annoying wannabe “guides”. Bargaining is a must. And make sure you remember the words “non, merci” as the eager sellers can literally harass you and follow you around.

A visit to Senegal is incomplete if you do not visit Goree Island. Reaching the ferry station by cab and then taking a ferry to it is easy. But me and my friend from India, both widely-travelled media persons, got conned into paying a non-existent tourism company for a trip to Goree Island, waited for hours for a bus that never arrived, laughed on our own stupidity, and ended up going to Goree on our own and having an awesome time. So when in the developing world, be a little smart smart!

Situated near Dakar, Goree Island is a quaint little tourism spot now, where old buildings including a slave house have been preserved in original form. It is a UNESCO World Heritage site. Only seeing it can do justice to its beauty. The Portuguese and Dutch architecture and the vibrantly painted small houses with bougainvillea in abundance makes Goree an eerily beautiful place to visit. It seems I was catapulted into the past.

It was a Sunday. The Muslim community of Goree had gathered that day for a congregation of sermons and they recited verses of the Quran and praises of Allah so beautifully in unison that I had a beautiful, spiritual experience, sitting under the trees at sunset. I will never forget that moment.

Built in 1776 by the Dutch, the Slave House at Goree Island is one of several sites on the island where Africans were brought to be loaded onto ships bound for the New World. The owner’s residential quarters were on the upper floor. The lower floor was reserved for the slaves who were weighed, fed and held before departing on the transatlantic journey. The Slave House with its famous “Door of No Return” has been preserved in its original state. Thousands of tourists visit the house each year, and celebrate the freedom of the human species from the clutches of slavery by re-visiting the past.

As part of my work, I had a wonderful chance to visit Thies which is the third largest city in Senegal, and two adjoining villages, as guests of “Tostan”. Tostan means “breakthrough” in the West African language of Wolof, which it certainly is. Tostan is an international non-governmental organisation with operations in over 500 communities across Africa, with a mission to empower African communities to bring about sustainable development and positive social transformation. Molly Melching, Founder of Tostan, made the visit to Senegal all the more meaningful. Her work as a human rights activist has helped almost eradicate the centuries-old custom of Female Genital Cutting (FGC) from Senegal. One of the villages we visited was Keur Siambara. Here we met Village Chief and Imam Demba Diawara, who according to Molly Melching is “a PhD in wisdom”! The one mantra Demba kept repeating that had much to be learnt, especially for activists, was: “Beautify Your Words.” Demba’s wisdom and that of other community members helped Tostan in achieving its aim. This has now led to over 6,200 communities choosing not to cut their daughters. It is entirely possible that Senegal could have ended this practice completely by 2015.

Apart from the learning experience, the hospitality and warmth of rural Senegalese people was a joy. We were welcomed among drum beats, merry dancing, and pretty girls twirling bowls made of gourd, as we were seated under a huge Neem tree. It was so unlike, yet so similar to Pakistan.

Senegal was amazing. I remember most the Belle soirées par la mer à Dakar (the beautiful evenings by the sea in Dakar), and the serenity I witnessed in that country. Eleven splendid suns, beautiful ebony complexions, serene azure waters and a wonderful slice of Africa — Senegal, you will be missed.

Unsafe abortions – The Silent Epidemic

http://jang.com.pk/thenews/nov2011-weekly/nos-06-11-2011/enc.htm#1


Life sentence 
Unsafe abortions are akin to a silent epidemic that claims lives of many women each year in Pakistan

By Farahnaz Zahidi Moazzam

In the heart of the bustling city of Lahore, on Temple Road, is a small clinic, infamous for being one of the quickest ways to get rid of an unwanted pregnancy. This is one of the many such clinics on the street. The clinic’s doors are open to any woman who comes for an abortion. While its staff promises to do the procedure safely and hygienically, its claim to fame is quite the opposite: Horrendous tales of incomplete body parts and remains of aborted foetuses floating past the open drains that run through the area are well-known.

As one enters, they welcome you warmly. A nurse introduces the patient to a lady who “claims” to be the doctor, who is lying on a bench and resting till the next patient strolls in. There is no way of confirming if the woman is a doctor or not. The first question they ask is which residential area the patient has come from. If the patient says she has come from an upscale area, the rates are threefold — Rs12,000 in the first month and Rs25,000 in the second month… and the rates keep escalating depending on how far the pregnancy has progressed.

“It is not my concern whether a patient wants to get it done because she made a mistake with a lover, or wants to abort a female foetus, or uses abortion as a form of family planning, or is healthy enough to carry the child to term or not. My job is to clean out her uterus within hours and send her home. That is all,” says the alleged doctor.

But don’t they know that for an abortion to be legal in Pakistan, the condition is “necessary treatment” which the health provider has to decide? Will they not check the woman’s health status? Her blood counts? And does it matter to them how far the pregnancy has progressed? The questions are dodged. They say they use “the vacuum method and other methods” for abortions.

The clinic is definitely not equipped to handle any post-abortion complication. And this is one of the relatively better clandestine abortion clinics that carry on with their business quite openly.

In another part of Lahore, the situation is bleaker. This is Shahi Mohalla, also known as Heera Mandi. Some 1,500 female sex workers inhabit this area. Contraceptives are not always accepted by their male clients, resulting often in unwanted pregnancies. Already poor, vulnerable to HIV and Sexually Transmitted Diseases (STDs) and exhausted, these women may call for Traditional Birth Attendants (TBAs) or “dais” for deliveries and abortions. But small abortion clinics are a more popular choice.

“Many of them lose the battle of life due to post-abortion complications. The methods used in these abortion clinics of the area are old-fashioned and invasive and often harsh methods that result in complications,” says Lubna Tayyab, founder of the NGO called SHEED (Strengthening Health, Education, Environment, Development) Society that is working for the betterment of sex workers and their children in the area.

Abortions in Pakistan are mostly obtained in clandestine clinics. Very few of these clinics are properly equipped to carry out abortions safely. Providers typically perform dilation and curettage procedures. They almost never used manual vacuum aspiration, a less invasive and safer procedure.

According to a report by National Committee for Maternal and Neonatal Health (NCMNH) and the Guttmacher Institute (Ref: http://www.guttmacher.org/pubs/IB_Abortion-in-Pakistan.pdf), a nationwide study estimated that 890,000 induced abortions took place in Pakistan in the year 2002. This amounts to 29 abortions per 1,000 women of reproductive age. Of every 100 pregnancies, 14 ended in induced abortion.

Deaths, long-term disabilities, health complications and a messed up reproductive system — these are just some of the side effects of an unsafe abortion. Complications can be incomplete abortion, hemorrhage or excessive bleeding, trauma to the reproductive tract or adjacent anatomical areas, sepsis (bacterial infection) and a combination of these complications. Excessive bleeding may have life-threatening consequences, such as anemia or shock. Perforations and lacerations may occur to the vagina, cervix or uterus and may involve injury to adjacent areas, such as the intestines, requiring surgery with full anesthesia. Hysterectomy (removal of the uterus) may be required, leaving the woman permanently infertile. If not treated in time, sepsis can lead to peritonitis (inflammation of the abdominal lining), septicemia (blood poisoning), kidney failure and septic shock, all of which can be life-threatening.

Unsafe abortions are carried out by methods that are a health nightmare. Gulping down large doses of drugs, inserting a sharp object into the uterus, drinking or flushing the reproductive tract with caustic liquids, vigorous movements like jumping or physical abuse, and repeated blows to the stomach are some of them. Incidences have been reported where bowels of the patient are pulled out by mistake, through the reproductive tract.

According to Population Reference Bureau, Women of our World, (2005), the lifetime chances of a Pakistani woman of dying from maternal causes is 1 in 31.

A 1999–2001 university hospital study found that 11 per cent of maternal deaths that occurred in the hospital during this period were caused by complications resulting from unsafe abortion.

However, reliable data on induced abortion is almost impossible to obtain. For something that is done so commonly, it is surprising how well it is hidden. While the evidence is limited, it is clear that post-abortion complications account for a substantial proportion of maternal deaths in Pakistan.

In 1990, the Pakistan government revised the colonial-era Penal Code of 1860 with respect to abortion. Under the 1990 revision, the conditions for legal abortion depend on the developmental stage of the foetus — that is, whether the foetus’s organs are formed or not.

Islamic scholars have usually considered the foetus’s organs to be formed by the fourth month of gestation. Before formation of the organs, abortions are permitted to save the woman’s life or in order to provide “necessary treatment.” After organs are formed, abortions are permitted only to save the woman’s life. (Ref: United Nations Population Division, Abortion Policies: A Global Review, New York: United Nations, 2002). However, generally, this is a debatable issue.

Since 1997, under certain circumstances, abortion is legal in Pakistan, not only to save the woman’s life but also to provide “necessary treatment”.

Most women who have induced abortions in Pakistan are married and already have more children than the average Pakistani woman wants. Thus, abortion is used as a form of family planning.

The average age of the women seeking abortions, reported in several studies, was just under 30. Research provided by NCMNH shows that 96.1 per cent of the women who seek abortions in Pakistan are married. “This shows that it is a misconception that abortions are common in unmarried girls who want to abort an illegitimate child,” says Dr Azra Ahsan of NCMNH.

“Also, female infanticide is not a problem in Pakistan, apart from isolated incidences. In 15 years of medical practice in Pakistan, I have not received a single request for termination of pregnancy on the basis of gender,” says Dr Sadia Ahsan Pal, also of the NCMNH.

Pakistan Demographic and Health Survey 2007 (PDHS) reveals that 41 per cent of urban married women of Pakistan use contraception, compared with 24 per cent in rural areas, while 25 per cent of Pakistan’s married women have an unmet need for family planning, both for spacing and limiting the number of children. This has a direct bearing on the probability of abortions, which is used as a form of family planning.

Unsafe abortions are a public health issue that needs immediate attention. Timely family planning and awareness about use of contraceptives can be the actual solution to this silent epidemic that claims many lives of women each year in Pakistan.

Older than her years

“I belong to district Lodhran in the Punjab. My father got me married off to my paternal cousin when I was 14 years old. My husband is older to me by some 13 years,” says 23-year old-Sughra, who looks much older than her years. She is a mother of two children.

Dark circles, breathless upon walking, dragging her feet, Sughra is displays the classic signs of anemia.

“A couple of years ago my husband beat me up so severely that I could not even swallow or lift my hand for days. I came to my mother’s house. At that time I was pregnant. I stayed on in my parents’ home and thought about ending the marriage. Having another child in such a marriage seemed like a bad idea. I was hurt, and took my revenge by deciding to abort the baby,” shares Sughra, wiping her eyes with a worn out dupatta.

“My mother took me to this daai who charged us Rs 1000. Her instruments were not clean. I still remember the rusty looking, stained metal probes she used. But what option did I have? I was about four months pregnant when I got it done. The daai had promised I would be on my feet the next day. But I was on bed for two weeks, bleeding profusely,” she recollects.

Sughra was finally taken to the nearest hospital where she ended up getting blood transfusions. “My health has never been the same ever since. The doctors said I could have died because of the bleeding and infection related to my abortion,” she says.

Sughra is now back in her husband’s home. He refuses to use any contraceptives, but Sughra now has started using injectable contraceptives. Her face, though, saddens every time she remembers that abortion.

— FZM

My Sojourn to Ethiopia – Day 7

As I sit down to write down my blog for that last, eventful day in Ethiopia, I am getting all “EMO”. Emo, short for emotional, is a term my daughter Iqra has introduced me to, and my friend and mentor Zofeen has labeled me with – an apt label, and one I quite like 🙂. Emo because of nostalgia. I miss those wonderful days. Writing this travelogue makes me re-visit all those days, one at a time.

I started writing this basically for myself, trying to experience an iota of what my favourite travelogue-writers and “earlier” bloggers experienced when they wrote memoirs – writers like the Mughal kings who each wrote a “Tuzk”, like Ghalib whose letters are forever fresh, like our own Mustansar Hussain Tarar whose travelogues have given me the inspiration to travel Pakistan from Karachi to Azad Kashmir by road. And then the women travel writers like Freya Stark and the more recent Elizabeth Gibert who stole my heart with “Eat, Pray, Love”!

I have enjoyed this journey of writing this. Many of you have accompanied me on this journey. Thank you for reading it through, from the beginning till the end, and for the encouragement you have given an amateur traveloguer.

Thanks to Women’s Edition, in a few months, I hope and pray another travel-blog will soon be written by me. Another country. Another experience. InshAllah 🙂.

17th June:

Debbie and Charlotte have warned us the day before that the last day will be back-to-back, full of lots of activities on the agenda. And the day begins with our visit to the office of Pathfinder International, an organization said to be a global leader in reproductive health.

Ethiopia: second largest country in sub-Saharan Africa with a growing population that is currently at 82 million people—more than half of whom are under the age of 25. 84% of Ethiopians live in rural areas where access to modern health care is often limited and harmful traditional practices, such as early marriage and female circumcision, are prevalent. Organizations like Pathfinder are fighting the odds with programs like the Integrated Family Health Program, HIV and AIDS care, Family and Reproductive health support, Fistula repair services, Family Planning services and many others.

So much work being done. But never enough. Work in the development sector always has a catch phrase: It’s never enough, yet you gotta do what you gotta do.

With Dr Adnew as our guide, we head St Paul’s Hospital, to visit the Cervical Cancer Prevention Unit working under Pathfinder. St Pauls is a typical general hospital. People queuing up, waiting for their turn to be seen by the messiahs. Nothing fancy. The typical smell of disinfectants. Clean, surprisingly. An old building. Flooring that has been smoothened out by the thousands of feet that have tread on it, as they entered the premises in search of healing.

Going around in labyrinth like hallways, we reach our destination….a tiny 3 room unit with the simple most equipment, and an old steel bed for patients. A very welcoming and warm-faced woman is there in a white lab coat, waiting for us. Haragewoine Garedew, Senior Nurse Professional, answers our curious and excited questions gently, as we stand around her, 15 of us cramped in a tiny room….a room that smells of disinfectants, is highly non-fancy, and yet to me seemed to be emanating some kind of symbolic light. This is the room where early detection of the earliest signs of cervical cancer of so many women has taken place, and has in turned saved their lives.

Cervical Cancer is one of those rare forms of cancer the cause of which can be contracting (refer to blog about Day 3 on this site). Early detection is key, because by the time the patient starts showing signs, it has already progressed considerably.

Pap Smears can detect it, but Pap Smears are expensive. And people in Ethiopia or Pakistan are generally not only unaware but also poor. At St Paul’s, they are using a far less expensive method to screen women for signs of cervical cancer. The method is one of direct visualization with acetic acid and has gained popularity and proven itself as an adequate alternative to PAP smears in developing countries. In visual inspection with acetic acid (VIA), 5% acetic acid is applied to the cervix with a large cotton swab and left for 30-60 seconds, after which the cervix is visually examined with the naked eye and a lamp. Pre-cancerous lesions, with a higher ratio of intracellular proteins, turn white when combined with acetic acid. Normal cervices without any precancerous lesions, do not change colour. It is low-cost, requires fewer visits to the physician and the efficacy is about 5 years. Women with pre-cancerous lesions are treated with cryotherapy. Women suspected with cervical cancer are referred for advanced care. Haragewoine and her team are performing this test on 10 women or more on an average at this unit in St Paul’s…….Potentially, saving ten lives a day!

My mind, expectedly, applies the knowledge I am gaining to my own country, my home, Pakistan. As it can be sexually transmitted, my observation and gut instinct leads me to the thought that the incidence of Cervical cancer in Pakistan is much more than we like to believe. The taboos linked with screening for STDs (sexually transmitted diseases) and the lack of awareness even among educated, urban women that a simple Pap Smear test can be a life saver….yes, Pakistan needs more awareness on this issue, like most developing countries.

On return from St Paul’s, we join a group of Ethiopian female journalists for a meeting and a lunch. They have what I sense in all African female journalists I have met – an inner strength and an inherent defiance that comes from having fought many battles.

Our last session together is interesting. We talk excitedly about the upcoming session in the Fall season. Suggestions are taken about which countries would be value-adding experience, and some of these are short-listed. Debbie and Charlotte gently remind us that we have to be “intrepid women” to be able to enjoy Women’s Edition and all it has to offer. We also discuss the work we all plan to do and issues we need to advocate through our writing or any other form of media in the months to come.

Habasha 2000. We are told that this is the name of the traditional restaurant where our farewell dinner will be held. Dressed to kill, all of us start gathering in the hotel lobby. We shriek excitedly upon seeing each other looking nice in formal clothes, and compliment each other. Kounila, Rose, Tetee and Montessori look beautiful in traditional Ethiopian clothes they have bought on their shopping sprees in Addis. We click away endlessly from our cameras, and have to be reminded that we must leave for the restaurant for the grand finale.

The restaurant is indeed a tour into traditional, cultural Ethiopia. The perfect ending. Great company. Amazing food. A cultural show that was a treat. Rich Ethiopian coffee. Laughter. Conversation. Nostalgia. Anticipation for the next conference. Hugs. Good byes. Promises to email each other the photographs, and stay in touch. And hugs and good byes again.

Back in my room, I pack frantically. There is a knock on the door. I know who it is. Shai, all pragmatic and practical on the surface, is already missing Addis, the team and me. We relish our last few cups of tea in Addis Ababa, in the chilly weather on my tenth floor balcony. Once the good bye is over, I am enjoying that last bit of time on my own in Ethiopia. Ethiopia – what a beautiful country. And how much it has taught me. Will I visit it again, ever? I wonder. I hope.