Sadiah Ahsan Pal  ( OMI Hospital Karachi, Association for Mothers & Newborns, National Committee for Maternal & Neonatal Health, Society of Obstetricians and Gynaecologists of Pakistan. )

Lack of formal reproductive health education in educational institutions in Pakistan and social taboos, leaves the majority of newly married couples unprepared to deal with sexual, social and health issues after marriage.
Early age marriage is prevalent in our society where 35% get married before 18 years of age and 54% by age 20 years.1 The median age for first birth is 22.2 years.¹ Many couples end up having children due to lack of knowledge. There is a Child Marriage Restraint Act, but little awareness of it.
Marriage is often forced in Pakistan. This is a cultural practice which is more prevalent in the rural areas. The spouse is mostly chosen by the family elders, not the couple themselves. This is despite the fact that Islam stipulates that the marrying couple must be willing and agree 3 times at the time of Nikah to ensure that no coercion exists. Psychological disturbances occur from inequality in social and financial status, education, nature of employment, earning capacity, previous marriages and children and a joint family system. Marriage is a legal contract with equal rights, obligations and expectations of a happy social union. Anti-Woman practices like watta satta, vanni, swara and chatti are rife in rural areas and need to be abolished through legislation and education of the masses.
Consanguinity is a cultural practice that has been going on for generations for convenience and preservation of wealth within the family, especially in feudal households. Nearly 50% of marriages are consanguineous in Pakistan.¹ This practice should be discouraged by medical professionals, as congenital malformations, autosomal recessive disorders and perinatal morbidity and mortality are higher in consanguineous marriages.²
The Nikahnama is a Prenuptial contract. Conditions can be outlined for dowry, polygamy, delegation of right of divorce, maintenance etc. It is the duty of the Nikahkhwan to ascertain the age of the bride, obtain informed consent, explain the clauses and provisions clearly i.e. nature of the nikahnama, delegate the right of divorce (or khula), dowry (timely payment of dowry), fair evaluation of deferred dowry and nikah registration. It is also his responsibility to ascertain whether it is the first marriage or not. If the husband is already married to another woman, to obtain written consent of the wife/wives and concerned Union council, before marriage is processed. Unfortunately the marrying couple is kept in the dark about the legal aspect, and the right to divorce is often crossed off on behalf of the bride without her knowledge.
Contraception should be discussed prior to marriage. Often there is family opposition to contraception, despite the couple\\\'s own wish to postpone pregnancy.
The most appropriate contraceptive method in early marriage is the combined oral contraceptive pill (COCP) for the woman, and condoms for the man. Unfortunately there are myths and misconceptions about the COCP. Mostly people are unaware of the non contraceptive benefits of the COCP, like decreased menstrual blood loss, decreased incidence of ovarian, colon and uterine cancer, and osteoporosis. COCP efficacy and safety is well established. The risk of death by ever users of the pill is considerably lower from all causes, as has been reported in the largest observational study on Contraceptive pill usage in Britain.³
Other health concerns prior to marriage include checking the Blood group, haemoglobin electrophoresis for Thallasaemia screen, and Rubella IgG antibody test for German Measles screen. Rubella vaccination should be done if found to be antibody negative prior to marriage/ pregnancy. HPV (Human Papilloma Virus) vaccination prior to marriage is also recommended for Cervical cancer prevention. Cervical cancer is a silent killer and is the 3rd most common cancer in Pakistani women. Its prevalence was 6.2% of 100,000 women in 2012.⁴ Women should also be given breast cancer awareness and taught self breast examination, as it is the commonest cancer in our women.⁴
Routine HPV vaccination of girls 9 to 14 years of age, is being done in developed countries. If this has not been done, then "catch-up" vaccination of girls and young women who are 13 to 26 years of age can be done as recommended by WHO (World Health Organization).5 After marriage regular Pap smears should be performed every 3 to 5 years. At least one pap smear should be done by the age of 35 years. Vaccination combined with Pap smear screening is the most effective approach to reduce the incidence of cervical cancer.
Thallasaemia is another public health issue in Pakistan.⁶ Consanguinous marriages contribute to the high prevalence. Thallasemia Major poses great financial strain on the family and health systems with excessive demands for blood transfusion. This is a preventable condition; counselling and screening should be done prior to marriage and conception.⁷
All Medical practitioners should undergo training in eliciting a comprehensive Sexual History and prescribing contraception.
Physicians generally have a highly respected position in society, and are capable of bringing about a change in the mindset of people. They should take part in advocacy programmes, and counsel their clients and families; form linkages with other Professional bodies/societies to disseminate information. There is an urgent need to address adolescent health education in Pakistan. Children are vulnerable and at increased risk of abuse, due to lack of knowledge about it. Paediatricians and Gynaecologists are aware of this problem, yet it is rarely addressed appropriately. All Physicians, Religious clerics, Educators and civil society need to take responsibility and disseminate sexual and adolescent health education in schools, colleges and prior to marriage in a culturally appropriate manner for a healthier married life. This has had a positive impact in several Muslim countries where Thallasaemia is also prevalent.⁸
There should be easy access to pre-marital health counseling, screening, vaccination and provision of contraceptive services. Gynaecologists and Family Physicians are well placed to address some of these issues, if consulted prior to marriage. This aspect of preventive medicine is neglected in Pakistan, and needs to be rectified by the government with legislation, advocacy and implementation.


References

1. National Institute of Population Studies (Pakistan) and ICF International 2013. Pakistan Demographic and Health Survey 2012-13. Calverton, Maryland USA: National Institute of Statistics and ICF International.
2. Hamamy H. Consanguineous marriages; Preconception consultation in primary health care settings. J Community Genet. 2012; 3: 185-92.
3. Hannaford PC, Iversen L, Macfarlane TV, Elliott AM, Angus V, Lee AJ. Mortality among contraceptive pill users: cohort evidence from Royal College of General Practitioners\\\' Oral Contraception Study. Philip C Hannaford, Lisa Iversen, BMJ. 2010; 340:c927.
4. Cervical Cancer in Pakistan. [Online] [cited 2017 January 10]. Available from URL: http://globocan.iarc.fr/Pages/ fact_sheets_population.aspx.
5. Human papillomavirus vaccines: WHO position paper. [Online] 2014 [Cited 2017 January 10]. Available from URL: www.who.int/wer/2014/wer8943.pdf?ua=1.
6. Ansari SH, Shamsi TS. Thalassemia Prevention Program. Hematology updates. 2010; 4: 23-8.
7. Asif N , Hassan K. Prevention of Beta Thalassemia in Pakistan. J Islamabad Med & Dent Coll. 2014; 3: 46-7.
8. Saffi M , Howard N. Exploring the Effectiveness of Mandatory Premarital Screening and Genetic Counseling Programs for b-Thalassemia in the Middle East: A Scoping Review. Public Health Geno. 2015; 18: 193-203.