Decision-making processes for female reproductive health in cultural context: A Case Study of Potowar Area

Abstract

This thesis intends to understand the cultural beliefs, attitudes, traditions and practices in a rural setting of Pakistan that drive the decision-making processes around female reproductive health.The study was conducted in village Jaffer of disuict Attock in the province of Punjab, Pakistan. Cultural interpretive and critical theories are used to map the decion-making processes. Participant observations, in-depth interviews, oral histOlies of illness expelience and patient-provider interactions are documented to infonn this thesis. The pluralistic healer enviromnent provides an easy geographic access to a wide variety of reproductive health practitioners including dais, hakeems, pir, shrines, chemists, public and private doctors and health facilities. Centuries old influence of Buddhism, Hinduism and Islam and traditional medical systems have influenced the perceptions and practices of local women about the common reproductive health problems. Kinship bonds and 'birdari' -dictates bind women to the cultural and social ideals of honour, chastity, docility and high feltility. Endogamy has facilitated marriages within the same village and strong bonds and interaction exist among the manied women and their natal kin. Eighty two percent of women visit their natal house either at daily, weekly or fortnightly intervals. The study elaborates upon the variables of female status and autonomy in a typical Potowar village. Nearly half of the women were illiterate and mostly married before reaching twenties. Maniage decisions due to their importance in one's life were surveyed. Among the ever-married women interviewed, 32% of women exercised choice for selecting their spouse. Ninety percent women report their inclusion in household decision-making though 38% also witnessed opposition to their decision at some point of time. One fourth of all ever-married women themselves could make a decision for seeking health care when sick. A large proportion (46%) depends upon the decision by their husband; 10% by their sons, 10% by the joint family and another 8% by the motherin- law to decide getting external help for health care. Only 36% ever-married women can 5 go to the health centre without seeking special pennission. Mother-in-law, sister-in-law, daughters and a woman's husband take care of household affairs in her absence. Ten percent respondents reported that no support is available. Thus it is observed that more social support is accessible to enable a woman to seek outside care in joint and extended households but the same living an-angements lessen female autonomy on the other hand by the need to comply with the joint and hannonious decisions by a larger family. Women attain status in the village by man1age, by beming sons and by enteling menopause. Female identity fOlmation and the ideals in the rural Muslim society of the village depict symbolic values of various reproductive illnesses which have strong implications for care seeking patterns. The uterus is considered the 'jaan' (life) of a female individual as it ensures her biological identity and prowess of fertility; the private parts are the reservoirs of a woman's and fmnily's shame and hence to be concealed togther with the ailments which have to be borne in silence; the concepts of 'paaki and pleeti' (pUlity and pollution) give lise to taboos related to menshual blood and the vaginal discharge. As a woman reaches menopause she also achieves the long lasting 'paaki' (pUlity) unman-ed by monthly cycles and child bem-ing. This pulity and relaxation in mobility and 'purdah' (veil) restrictions give her an elevated status. Traditions, rituals and religion knit a web of meaning in a woman's life. Being a 'zanani' (female) in the village only gathers status by virtue of being 'halalan' (chaste); 'suhgan' (cun-ently manied) and being able to produce an offspling. Motherhood and total obedience to one's husband including related concept of 'self annihilation/self-saclifice' is glOlified. Women make an effort to uphold these ideals of female viltue even dming sickness. Chastity, docility and stoicism lower a woman's chances of being an active partner in matters related to her sexual health and her negotiation power. Health is understood as the ability to be able to fulfill one's domestic and sexual roles ( poora kar sakna' (ability to deliver). Illness recognition comes with inability to perfonn one's routine tasks or by physical variability in body. Seeking care is linked with the 6 perceived cause of an illness. Local belief systems hold illness as a sign of Divine wrath; a predestined event or a result of an evil eye, magic or 'be-ihtiaati ' (carelessness that results in imbalance of hot and cold humours in the body). Reproductive illnesses are classified as pertaining either to vagina, uterus or breasts and include variations in libido. Uterine illnesses comprise the largest category including menstrual problems, issues of infertility, pregnancy and child birth related complications, 'naaf girna' (tipping), tumours and prolapse. Efforts to regain 'health' or curing an illness include household remedies, indigenous use of certain herbs, vaginal tampons and manipulations by dais, prayers at shrines and use of amulets and 'dam' (breath). Modem medical care IS occasionally sought from the Lady Health Worker, Lady Health Visitor and doctors. The decision-making processes are linked with the local concepts of menstruation, sexuality and menopause. The advice by 'dais' (traditional birth attendants) dominate the practices and care-seeking for conditions related to pregnancy, child birth and puerperium. The narratives of women demonstrate their struggle to seek reproductive health care for managing their fertility and infertility issues. Children are valued to fulfill one's maternal aspirations and procreative ability, to gain the status of responsible adulthood, continuity of the lineage, old age support of parents and means of going to heaven in the afterlife. A higher than actual desired fertility is aimed to guard against high child loss. The motives of fertility regulation include completion of desired family size, the high financial cost of rearing, aspirations to stay free of responsibility, avoiding division of property, fear of having young orphans if children are bom in later age, and avoiding embarrassment of simultaneous child bearing among two generations of women. The study concludes that reproductive health decision-making among females is a product of the cultural ideals of the female body, sexuality and extrinsic factors. Positive status change is gained by life transitions of menarche, marriage, fertility and menopause. Care is sought only if the illness causes a hindrance in perfonnance of a woman's gender roles that vary with the stage of her life cycle. The locus of control by self and choice of providers is positively associated. Traditional and faith healers enhance the feeling of 7 control and empowennent. Modem health care providers and their therapeutic regimens, on the other hand, allow little patient participation in illness management. The conformity between cultural values of patient and provider detemunes patient satisfaction. Culture is more detennining in framing decision-making than the availability of services and economic cost; the study shows continuity of traditional nOl1TIS even if awareness is present and modem health services are accessible.