Wednesday, April 14, 2010

Some ideas for research

1. Counseling of soon to be or newly married couples on reproductive health, lessons to be implemented from Iran, Jordan and Bangladesh experience. It seems that RH-Aid, a Islamabad based NGO initiated by Dr. Tariq Rahim has already started working on this idea by forming a facebook group by the name Premarital Counseling. However the facebook page does not provide any information about the activities of this group.

2. To what extent has the family planning programme achieved its goal of promoting two-child norm? Why is the ideal family size stagnant at 4 despite 5 decades of strong family planning campaigns endorsing of the benefits of two children? The ideal of 4 children is across the board in Pakistan. Women, whether they are from Balochistan or Punjab, from rural areas or urban, have education or not literate, more or less all desire to have four children.

3. What have we gained from the policy recommendations of large scale national surveys conducted so far. The study proposes an audit of the the state of research advocacy in maternal health the last 20 years.

4. Breastfeeding practices. What do people do and why? It is customary to discard first milk of the mother.... Cultural practices like insistence in of giving ghutti (prelactal) as the first feed, because of the belief that it carries on the traits of the person who gives it to the child may pose the newborn to unnecessary infections. A child who was fed ghutti may be breastfed exclusively after wards, but exclusive breastfeeding does not remain exclusive for too long because women believe that the baby needs at least water along with breast milk.

Monday, April 12, 2010

Who should be the advocate?

This is in direct response to Research and Advocacy Fund Pakistan's call for proposal for research and advocacy projects in Pakistan. The proposition begs the question to learn about what has happened so far to the advocacy recommendations. To what extent the research has been used in advocacy campaigns for policy or program and have materialized into the needed change.

Moreover, there is always a gap between the group conducting the research and the group who are capable and/or are interested in doing the advocacy part. It is rare to see a breed of researchers who are interested and also skilled in such utilizing the findings of their research for advocacy. I think the reasons behind such a gap are lack of realization on the researchers part that research itself is not an end in itself and just "informing" policy makers does not do the job. Secondly usually research grants do not include advocacy/research utilization component and hence researchers keep on jumping from one research project to another without ever thinking about using the results to their full extent. Thirdly, even if researchers are aware of the need of advocacy and also have the resources they may not be capable to do it on their own. In that case if an advocacy firm takes on an issue (such as abortion, emergency contraceptive pill) they may be strong in all aspects of building a campaign but may not know the technical aspects of the issue. Therefore, I think, in general, all research projects should include a component of utilization of findings and the project should not be considered complete till results are shared with with all the macro and micro stakeholders. Moreover, all project proposals should provide benchmarks and goals about advocacy once the results are finalized with clear indication of the responsibilities and time line.

And I think for real advocacy and campaigns which work, the researchers, program managers and communication/advocacy specialists have to join hands.

The gap between findings and policy of family planning in Pakistan

The latest statistics from Pakistan put Research has shown again and again that people in Pakistan are more comfortable with traditional family planning methods such as withdrawal, safe days and condom (PDHS 1990, 2006-07). These three methods account for almost half of the contraceptive usage in Pakistan (14.5 percent women use either of the three methods while CPR is 29.6 percent).

Non hormonal methods such as withdrawal is the one of the most favorite among most married men and women of the country (Casterline, Sathar and Haque 2001) just because it is free, readily available and has no side effects. The caveats are higher failure rate than hormonal or other barrier methods and dependency upon husband's cooperation to use. I personally consider withdrawal superior over condom and safe days method. For condom usage access (including geographic, financial, social and personal) still remains a barrier, cumbersome to use when sex is a quick act in a room shared with family members, requires storage and disposal after usage both of which may violate privacy for couples in country like ours where most people share sleeping areas with others.

Harmonal methods including pills, injectables and IUD which are considered the best also have the worst side affects. Fear of actual and perceived side effects lead to non use and discontinuation of contraception. Based on my personal conversations with colleagues who are involved in family planning research I learnt that withdrawal and condoms are the most favorite and the very same people who promote (in whatever way) hormonal methods would not consider those methods for themselves. A quick look at the latest PDHS data also shows that contrary to the expectation, the users of withdrawal and condoms are more educated, urban and more resourceful than users of injectable and pills. My point is that if people learn how to use traditional methods (Withdrawal, safe days, LAM) and modern methods at the same time, they would most probably go for the latter, unless they have completed their desired family size--for which they would prefer female sterilization.

Despite such findings, it is baffling to know that the emphasis of our government is always on promoting the so called modern (mostly hormonal) contraceptive methods, all in the name of effectiveness. I agree that effectiveness should be important, but in the scenario where accessibility and non-existence of side effects support natural methods and many would rather take chances of pregnancy rather than using a modern family planning method. I think in such cases the benefits of modern methods are seriously undermined where people are willing to go as far as induced abortion due to lack of use. (Please note that in Pakistan almost a million abortions are conducted every year)

Friday, April 09, 2010

Every Mother Counts

Reproductive health encompasses any factor which has direct bearing on human reproduction and reproductive ability. The spectrum of RH spans from menstruation, sexual health, fertility, child birth and maternal health, breastfeeding and care of the new born, family planning to menopause.

Given the personal and sensitive nature of this terrain, it is a much neglected topic in our country. Be it at a state level or home talking about of RH is mired in shame and cultural taboos. Unmarried youth are especially kept far from any kind of information with the idea that they will come to learn about these things when "time comes", implying after marriage and the child birth. There is no formal mechanism for the youth of Pakistan to learn about any aspect of RH till they are in dire need or have suffered consequences of lack of knowledge. On one hand we are against providing the so called sex-education, which may be a vehicle for imparting life saving information to youngsters of the country and on the other we have certain cultural practices which are harmful and detrimental for health. For example it is common practice in Pakistan to give Ghutti (usually honey, and sometimes spit of an elder) to a newborn, while medical research has proven that the best food for the baby is mother's milk which should be given right after birth.

Considering the nature of distance of Pakistani youth with health issues, the JHUCCP, PAIMAN Pakistan and White Ribbon Alliance Pakistan organized a painting competition on the topic of maternal deaths at the University of Fatima Jinnah Women University, Rawalpindi on 9th April 2010. Thirty students (mostly females) from Fatima Jinnah University, Federal Government Women's College F-7/2, Islamabad, National College of Arts, Beacon House and City School took part in the competition. The paintings were all themed around maternal health and mortality and were created using oil paints on canvass. Average painting was about 3' x 2'.

It was a mega event entitled "Every Mother Counts". Deputy Speaker National Assembly Mr. Kundi, Dr. Nabila Ali the Chief of Party of PAIMAN, Director of National MNCH Program, Dr. Amanullah Khan of White Ribbon Alliance along with the Vice Chancellor of Fatima Jinnah University presided over the proceedings. Dr. Ali shared overall situation of maternal mortality in Pakistan and enlightened the audience about the direct and social causes which contribute to maternal deaths and morbidity. Dr. Khan presented the state of newborns in the country. Dr. Ali and Dr. Khan's presentation on maternal and child health went very well with the students and I am sure they went home with renewed interest in doing something to save the mothers and newborns of Pakistan. After the proceedings, two of the best paintings were given cash prizes, judged by renowned artist Mr. Jamal Shah.

While the paintings were amazing and captured the theme of the plight of maternal health issues (especially maternal mortality) very well, I was seriously disappointed by the "youth perspective" on health status of women of Pakistan, provided by two bright women of the organizing university. The girls had the perfect pitch and delivery in English with an eloquently written text on the topic but failed to deliver what the topic of their presentation promised us--the youth perspective. While listening to the students, I felt that they do not know where and how to access good quality research material related to RH in general and in particular maternal health. I laud their effort and courage in presenting their ideas in that august forum but at the same time I think their talent and time was wasted. If finding the state of health of Pakistani women was so hard, they could have gathered the views of fellow students of the very topic which would actually have provided the "youth perspective" on the topic!!

But anyway, in my view, one small thing that the research/NGO sector can do is fill the knowledge gap. I think a handboo and/or website on RH in Pakistan with latest statistics, a short description of the rates and ratios and sources of information and sources of data and information would go a long way in at least spreading information which will hopefully lead to better knowledge and improved attitudes and behavior for RH.

Thursday, April 08, 2010

The road to Multan (29 March 2010)

Let me confess that when I started my journey towards Multan, I had certain pre-conceptions about South Punjab. I was all aware of the recent "Talibanization" of Pakistan, especially the fact that the Taliban brand has taken foothold in Punjab too!!! Hence, I took the road trip with a certain sense of trepidation and adventure and let the driver use the famous and infamous Multan-Mianwali Road instead of the motorway! Yes I did expect to see the roads filled with Go America Go slogans or extra ordinary surge towards Islamization, like wall chalking to enforce purdah, anti movies and music etc. My imagination was fertile with the activities of the Lal Masjid moral police of 2006 and before.

However, as the car moved along and left central Punjab the things I noticed most were large wall advertisements of hakims promising treatment for all kinds of male sexual problems, mobile phones, soothsayers and black magic practitioners who supposedly solve all problems include bringing your lover to your feet and sending you to america! Come Minawali, I notice a impressive university building, NAMAL which will start its first session in Fall this year and is affiliated with Bradford University UK. Had lunch from a roadside hotel. Note it was not a driver hote. My driver thought it was safer and more respectable to take me to a proper hotel. Upon entering the restaurant felt a bit intimidated with the hall full of males in traditional garb and features that are hardened with life. I sensed a momentary unease and made sure that my chador covered my body and head fully and asked to be seated... The manager said that he will find a room for me and pointed to a waiter for help. I said, no I am OK if u can give me a corner place to sit but they insisted and i was taken to a room on the 2nd floor of the hotel. I was told that they are having a party downstairs and i will not be comfortable there. Of course i did not expect any women to attend the party and hence felt better sitting in a room to have lunch... The food, chicken curry (even though they had a selection ranging from all kinds of Pakistani and Chinese dishes) served by a young flirtatious waiter was extremely delicious! The lunch was uneventful otherwise.

Multan was still 4-6 hours away. My excitement started fazing out when i saw several accidents on the way. Combined with the fact that it was hot and i had forgotten my ID card at home I started worrying a bit. To distract myself I took out my camera and started shooting anything that i found interesting and was possible to be snapped!

Throughout the event I did not notice anything peculiarly different than my previous trips to this region in 1998, 2003, 2004 and 2007 with the exception of dryer rivers and inundation of the region with mobile phone company ads. Politeness, piety, purdah, and poverty, seemed the same, perhaps the later perhaps had increased in the last few years. During the whole journey the only thing I could think of was the sufis, saints and the legendary lovers from Punjab and Sindh who seem to be the biggest source of inspiration and comfort for people who live there.

However, I knew that the notorious Pak-Afghan border region of DI Khan and Wana are not too far and could not stop thinking about the terrorism and its causes. I had also heard about the seeping of such ideologies from the borders to Waziristan and then to Punjab. However, at the same time I could not reconcile with the fact that the lovers love stories and sufi teachings could or would embrace any form of Talibanization. Where do I find an answer to such an anomaly, if there is such such thing. Is the desperation for survival so bad for some people that they would give up their traditions of generations of non violence and agree to blow themselves up to kills others? I could not see any form of such desolation. Of course my trip was too short to make any judgment about what was actually going on there. Should I also try to find my answer in conspiracy theories which purports that the streak of violence in Pakistan is mediated by India and Israel! Whatever the answer is, the fact remains that terrorism is a sad reality of Pakistan and terrorists come in all forms, shapes, colors and ethnic groups. Perhaps my I was also bewildered by the fact that we talk about sufism crushing the slafi brand of Islam but I do not see how that could be done when the followers of saints could be lured to the dogma of vengeance and intolerance.

I guess my journey made me realize that more than terrorism, Pakistan's biggest threat is looming crisis of food, water and power shortages for the fast growing population. The general public seem not to care or know about Blackwater, details of KL bill, the Mehsuds and the Bradars. They just want to survive and let others survive.