February 2005, Volume 55, Issue 2

Editorial

Girl Child Today - mother of a nation tomorrow

Qudsia Anjum  ( Department of Community Health Sciences, Ziauddin Medical University, Karachi. )

Pakistan has lagged behind from its neighbours and other low-income countries in terms of Health and Population outcomes. Total life expectancy is 61 years with 64 years for males and 66 years for females. Adult literacy rates have increased to 43% with adult female literacy of 28%. Women in reproductive age constitute 23% of total population. The sex ratio in Pakistan is adverse to women, 106:100. Population growth rate is 2.13% annually with total fertility rate of 4.1. Maternal morality rate ranges from 350 to 400. One of the major reasons of high maternal mortality is poor access to prenatal care (28%)and dearth of trained attendants at birth (20%). Low birth weight infants account for 19% and of all pregnant women, 57% are immunized for tetanus.1,2
A recent literature review presented the socio-cultural, environmental, and health challenges faced by the women and children residing near the borders between Afghanistan, Iran, and Pakistan. This analysis revealed that this underdeveloped region is facing an array of problems. Health is compromised, which may be attributed not only to poor hygiene, lack of water, but also limited knowledge and lack of access to health care services. In addition, cultural, political, and socio-environmental factors play a role, including gender inequality.3
Most mothers are malnourished, and this malnutrition starts even before they are born, right from the womb of their mother. After birth they are deprived of the usual care and male child is given preference in all aspects, whether it is education, food or clothing. A study done in India showed that the educational status of girls was lower than that of boys and the priority in a girl's life during school going age was marriage.4 As the girl child is near to reaching puberty they are stopped from eating meat and related products as they are assumed to be a part of food fad in enhancing puberty. Thus again girls are deprived of protein and iron rich foods hampering their growth and development resulting in stunting and often with too small or deformed pelvises, making it difficult to deliver a child normally. Studies prove the importance of maternal nutrition in preventing pre term and low birth weight babies and thus further improving the nutrition of children especially girls.5,6 Anaemia is one of the important factors that hampers the daily activities in almost every woman and multiple pregnancies even makes it worse. Low maternal hemoglobin levels are associated with increased risk of pre-term delivery, LBW babies, and intrauterine deaths.7
Education of a female child is either not initiated, or if initiated, she has the right to complete her primary levels only. Educating girls has repeatedly shown to increase their self-esteem, and to increase their influence over their own lives and family and community decisions, to lower fertility, to improve maternal and child health, and to help in decreasing environmental degradation. Despite the advantages, considerable resistance still exists against educating girls in developing countries. Believing that boys who start school will complete their education, acquire employment, and earn wages to contribute to the well being of the family, parents encourage boys to attend school and girls to remain at home to help with housework and raising younger siblings.8
Early marriage is another factor creating adversities for the female gender. Multiple pregnancies, prolonged breast-feeding, and usual household chores, never let a woman come out of the morbid state. With each successive pregnancy, the maternal iron stores are depleted making malnutrition progress further. A study on maternal risk factors showed that early pregnancy had put the adolescent mothers at stake for unwanted pregnancy and obstetric complications. Women empowerment through compulsory girls' education would be the most effective strategy to prepare them for at recommended age marriage, planned and delayed pregnancy, and better motherhood.9
Compilation of available data on maternal mortality figures in Pakistan showed consistent high numbers. The leading causes quoted were hemorrhage, followed by sepsis, eclampsia, rupture of the uterus, and abortions.10
Safe motherhood initiative has articulated ten action messages that highlight critical intervention for reducing maternal morbidity and mortality and the range of barriers (economic, legal, social, and cultural) that women face in accessing high-quality maternal health care.11
Access to antenatal care, lack of knowledge about obstetric complications had been identified as major problems for women in rural areas of Pakistan.12 The article by Alam AY in this issue addresses the difference in knowledge regarding identification of danger signs in pregnancy and prevalence of anemia and tetanus toxoid coverage between women attending antenatal care and those not attending. Another study done in Karachi revealed that women receiving antenatal care were more knowledgeable about the importance of dietary protein and intake of green leafy vegetables for the prevention of anemia and reporting danger signs.13
Advice to mothers in antenatal clinic focuses on provision of iron and folic acid supplements, care of newborn, breastfeeding, nutrition of child and family planning. What is lacking is advice on her change of state from woman to a mother, the importance of her keeping healthy, and the decision to become pregnant. Antenatal visits can prove to be a platform for advising women on the physical, physiological and psychological changes during pregnancy; nutrition and immunization of the newborn and mothers; proper birth spacing; prevention of malnutrition. A study highlighted not only poor reproductive health indicators among Afghani women, but also that majority of them needed authorization from their husbands to seek health care.14 Postpartum depression is also one of the major morbidity affecting maternal health, which could be, addressed in the prenatal period. A study reveals that examining specific risk factors in women of lower socioeconomic status, risk factors pertaining to teenage mothers and the use of appropriate instruments assessing postpartum depression can be of help in reducing this state.15
It is high time we should invest in women's health and in the health of the future generations by taking good care of the girl child. Indeed girls who develop healthily, confidently, and are strong are more apt to have a safe motherhood and nurture their own children so they can reach their full potential. The deprivations this gender faces, result in death, if not death, poor health throughout life puts them at a greater risk during pregnancy and childbirth. Finally, it influences a girl's mental ability to manage motherhood. Moreover, it reduces self-esteem, which in turn renders them reluctant to demand improvements in maternal care.
Drawing aside the curtains of development and scratching beneath the superficial progress, one discovers that even today prevention is better than cure. Dwelling in a developing country one is faced with the challenges of economics, lack of education and resources. When health needs are marginalized, community awareness and mobilization becomes the key tool for disease prevention, health promotion and health education of a nation.

References

1. Pakistan Demographic Survey 2001. Federal Bureau of Statistics. Statistics Division. Government of Pakistan. RL:http://www.statpak.gov.pk/depts/fbs/statistics/pds2001/pds2001.html
2. State of the World's Children 2005. UNICEF.
3. Poureslami IM, MacLean DR, Spiegel J, Yassi A. Sociocultural, environmental, and health challenges facing women and children living near the borders between Afghanistan, Iran, and Pakistan (AIP region). Med Gen Med 2004;6:51.
4. Ananthakrishnan S, Nalini P. Social status of the rural girl child in Tamil Nadu. Indian J Pediatr 2002;69:579-83.
5. Mitra K, Chowdhury MK. Maternal malnutrition, perinatal mortality and foetal pathology--a clinicopathological study. J Indian Med Assoc 2002;100:85-7.
6. Feresu SA, Harlow SD, Woelk GB. Risk factors for prematurity at Harare Maternity Hospital, Zimbabwe. Int J Epidemiol 2004;33:1194-201.
7. Lone FW, Qureshi RN, Emanuel F. Maternal anaemia and its impact on perinatal outcome. Trop Med Int Health 2004;9:486-90.
8. Fishel J. Educating girls: population growth's silver bullet? ZPG Report 1998;30:3.
9. Shrestha S. Socio-cultural factors influencing adolescent pregnancy in rural Nepal. Int J Adolesc Med Health 2002;14:101-9.
10. Jafarey SN. Maternal mortality in Pakistan - compilation of available data. J Pak Med Assoc 2002;52:539-44.
11. Priorities for Safe Motherhood. Safe Motherhood.org. [updated 2002] [Copied 7 January 2005].http://safemotherhood.org/smpriorities/index.html
12. Safdar S, Inam SN, Omair A, Ahmed ST. Maternal health care in a rural area of Pakistan. J Pak Med Assoc 2002;52:308-11.
13. Nisar N, White F. Factors affecting utilization of antenatal care among reproductive age group women (15-49 years) in an urban squatter settlement of Karachi. J Pak Med Assoc 2003;53:47-53.
14. van Egmond K, Naeem AJ, Verstraelen H, Bosmans M, Claeys P, Temmerman M. Reproductive health in Afghanistan: results of a knowledge, attitudes and practices survey among Afghan women in Kabul. Disasters. 2004;28:269-82.
15. Robertson E, Grace S, Wallington T, Stewart DE. Antenatal risk factors for postpartumdepression: a synthesis of recent literature. Gen Hosp Psychiatry 2004;26:289-95.

Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees: