The distinct roles and behaviors of men and women in a given culture, dictated by that culture’s gender norms and values, give rise to gender differences. Not all such differences between men and women imply inequity but they do give rise to gender inequalities – that is, difference between men and women which systemically empower one group to the detriment of the other. The fact that, throughout the world, women on average have lower cash incomes than men is such an example.
Both gender differences and gender inequalities can give rise to inequities between men and women in health status and access to health care. Women in Pakistan have fewer choices and opportunities and live very different lives from men. Gender inequities affect many areas of their lives and they are forced to live under different circumstances from men from the beginning of their lives. They bear multiple responsibilities, have fewer choices and opportunities and little personal liberty and autonomy to make decisions. The consequences of this are reflected in the indicators of poor health status, very low literacy rates, exclusion from ranks of economically productive population, increasing incidence of physical and sexual abuse and declining legal and social status.
These poor indicators are most tallying in Maternal and Neonatal Health scenario where Pakistan has one of the worst maternal mortality ratios in the region. Nearly 30,000 women die each year in Pakistan due to pregnancy related causes; in most of these cases the deaths are preventable. It is estimated that nearly 50 mothers die each day from pregnancy and child birth in Pakistan accounting to a death at every minute. This is a “silent emergency” – silent because it is happening outside the public eye and outside the policy maker’s field of vision. Maternal mortality is often considered responsible for the “missing women” in Pakistan’s population statistics. Adolescents’ females, aged 15 to 19 are twice as likely to die as women in their 20s.
The nutritional status of the population, especially of pregnant women, is highly unsatisfactory. The Pakistan National Nutritional Survey 2011 shows that 11.5% mothers and 15.1% of lactating mothers are malnourished. Iron deficiency was found in 47.1% mothers. Clinically, anemia was present in 26.2% mothers, 2% being severely anemic. It is believed that poor nutritional status of women is due to the discriminatory attitude that infant girls receive in a household of less resources. Anemia is the leading cause of post-partum hemorrhage, which is the number one reason of maternal deaths.
The other reasons are the denial of girl’s right to education by an early marriage. Though the mean age of marriage has increased in Pakistan to 22 years but it is still low in rural areas. The low practice of contraceptives is another reason for “too many pregnancies, too frequently”. The percentage of “unmet need” in family planning programs remains high with little attention from policy makers.
In the past, several health policies have been outlined, and strategies prepared to address the needs of women in the maternity cycle. They have not been comprehensive or focused on Safe Motherhood. Maternal and neonatal mortality and morbidity continue to remain high, and need to be addressed as a priority. It is recommended in this situation that the reasons for “three delays” in Emergency Obstetrical Care needs to be comprehensively addressed through advocacy, educating the couples & families, availability of transportation and fully equipped health facilities.
The dilemma continues in many forms and poses several challenges for Reproductive Health activists and supporters. Tradition and culture seems more restrictive for women as they are expected to suffer in silence. The cultural factors such as low status and lack of decision making power, poor nutritional status, limited husband’s involvement in parenthood, keeping pregnancies within four walls of the household and home deliveries by unskilled service providers are major determinants of women’s vulnerability for falling prey to maternal mortality.
Women dying needlessly during child birth want our attention and together we can save them. Programs focusing on women’s health issues needs to be formulated along with gender sensitive policies to bridge the gap of gender inequities. Birth spacing needs to be positioned strongly to improve CPR and to reduce IMR and MMR (MDGs 4&5). Policies should be supportive of sending girls to school and retaining them in secondary classes for delaying the age of marriage and providing them opportunities for higher education and employment. (MDGs 2&3). These solution levers are pressure tested, having ample evidence to be adopted in policy frameworks and reinforce into global agendas.
Dr. Yasmeen Sabeeh Qazi,
Senior Country Advisor, Population Program,
The David and Lucile Packard Foundation – Pakistan