Dr. Habiba Hasan, a pediatrician by profession, is one of the most respected educationist and human rights activist. Currently, a senior member of the faculty at Jinnah Medical and Dental College Karachi she has devoted more than forty years of her life to her professional work as a doctor as well as to improve the lives of children and women in Pakistan and Sindh. She has pioneered many projects and has been the first Pakistani to head Amnesty International representing it at various global forums including United Nations. She has been on various boards of governmental and non-governmental organizations pursuing and fighting for the rights and justice for women and children.
What kinds of disparities in maternal health are found between people in different social classes within our society? What kinds of disparities in maternal health are found between people in different social classes within our society?
Pakistan human development indicators such as health and education are marked by high levels of disparities. There is wide variation of population, income distribution patterns and access to basic needs such as health care and education. Multiple factors that include the pre-conception education level, health status, the social class and financial standing especially of the mother-to-be impact maternal health directly as also the decisions concerning pregnancy and antenatal care across the society. The poor and vulnerable segments of society face the brunt of the situation. A huge number of women lack access to any health facility let alone to pre-natal and antenatal care. Low awareness and lack of acknowledgement of the basic rights for women compound the situation. Maternal health, pregnancy, child birth and antenatal care are largely neglected and treated mostly by traditional means and thought of with regional attitudes. For example I have observed in my practice that decisions concerning pregnancy and birth are usually not made by the expecting parents and remain the prerogative of the elders in the family or community. Many of these women rarely undergo any check-up during pregnancy; whereas ideally they should see a doctor, 3 times or at least twice in the later stages of pregnancy, if not in the earlier months. Also intake of required nutrients is neglected and females are often deficient in calcium and iron which results in anemia, retarded fetal growth, and other complications. A large section of society relies on child delivery undertaken by untrained mid-wives. Moreover, intake of drugs without prescription during pregnancy is a common practice, affecting the to-be-born baby adversely. Lack of spacing due to cultural and social factors adversely affects the health of the mother as well.
While many of the poorer communities suffer from deficiencies or malnutrition, a general lack of awareness exists amongst the more affluent households. The ignorance about the dietary and physical requirements of females before, during and after pregnancy at times results in unhealthy diets and hence poor maternal health.
What commonly found health conditions should women be careful of before and during pregnancy?
Health conditions such as diabetes, high blood pressure, rubella (German measles) all need extra care during pregnancy. Rubella if contracted by a pregnant mother can be problematic because it can retard the mental and physical development of the fetus as well as cause birth defects. It is best to receive a Rubella vaccine a minimum of one month before trying to become pregnant or the baby will be born with Rubella syndrome. So women who are planning on getting pregnant should get a medical examination done to specially detect whether they have any sub-clinical disease like diabetes, hypothyroidism etc. If they have not had rubella vaccination previously, they should have one taken now.
Diabetes is a matter of concern also. It can result from afamily history, being over-weight or induced by other health problems. The first 3 months of conception are most critical as the embryo and other organs form during this period and uncontrolled diabetes at this time can lead to birth defects and a higher risk of miscarriage. Insulin is preferred over oral drugs to reduce blood sugar because oral drugs can be damaging to the fetus. High blood pressure can also be dangerous for both the mother and the fetus. Taking steps to control it before and during pregnancy and getting regular prenatal care is important to lessen or avoid related problems. Also women with chronic hepatitis B infection can transmit the virus to their babies at birth. Therefore, pregnant women should test for hepatitis B infection and receive vaccination accordingly.
How does abuse affect pregnant women and the newborns?
There is a wide prevalence of both physical and substance abuse particularly in the lower income segments of our society. What makes the situation worse is the general lack of awareness that a fetus is highly sensitive to maternal emotions as well as to drugs or other physical traumas the mother endures. There can be disastrous effects on the unborn baby of prenatal exposure to such direct abuse.
Violence during pregnancy for instance, creates feelings of anxiety, increased heartbeat or frightened speech in the mother and these are instantly communicated to the fetus. When the mother is tense or anxious, the hormonal factor comes into play and the baby kicks and starts to stumble in the womb. When the mother is under such stress the baby is seen on the ultrasound screen frowning in the womb. These experiences may contribute to pervasive feelings of insecurity and vulnerability as children grow up.
There are many other types of abusive behavior which hurt just as much or more than physical abuse. For example psychologically abusive situations within households emanating from issues such as unwanted pregnancy, gender of the baby or poverty are not uncommon. The resulting tensions with spouse or in-laws affect the baby both during and after birth. Simply being an eyewitness to such abuse can cause significant behavioral and/or emotional problems in children and may result in relationship difficulties later on.
Drug abuse also carries the double danger of harming the mother’s own health as well as impairing prenatal development during pregnancy. An abusive substance such as heroine, tobacco, etc. and even certain medical drugs must be avoided from the time a female first plans to conceive or learns that she is pregnant. During the first ten weeks of pregnancy most of the body organs and systems of the baby-to-be are formed and substance abuse at this stage can cause malformations of the heart, limbs or facial features. During the later stages of pregnancy, certain drugs may damage organs or even increase the risk of spontaneous abortion, premature delivery or growth retardation. Talking of specific examples, smoking by the mother during pregnancy hinders fetal growth and raises the risk of miscarriage and preterm delivery. Women who are addicts of heroin, LSD, glue, amphetamines and/or alcohol run the risk of chromosomal and congenital abnormalities, and all the same effects as of smoking. After the delivery, babies born to addicted mothers begin to experience withdrawal symptoms which can even at times be life threatening. In addition, continued usage of such drugs or their abrupt withdrawal induces mood swings, irritability, exhaustion and anger in the mother which often results in her lashing out on children.
Recreational drugs such as chalia (betel nut), paan (betel leaves), tobacco, shisha, gutka, etc. are also popular mostly in the lower income groups and cause serious health issues. These drugs are cheap and readily available and do not have the social stigma attached as smoking does. So women consume them openly which not only affects their health but also increases the risk of having premature and low birth weight babies. What is worse is that since the mothers continue consumption post-delivery, the effects of intoxicants found in the drugs keep reaching the infants while they are on the mothers feed. The money they waste on these could be spent on healthy nutritive food.
As part of my profession I continue to educate women that any drug they take passes through the placenta into the bloodstream of the fetus. Even drugs which have been prescribed by a doctor could be harmful to a developing baby. Therefore no drugs or even medication of any kind should be taken without physician approval.
Multiple factors including the preconception education level, health status, the social class and financial standing especially of the mother-to-be impact maternal health directly as also the decisions concerning pregnancy and antenatal care across the society.
What are the ways to cope with, reduce and prevent situations of abuse and stress?
We all need to realize that a happy mother will give birth to happy babies. There is nothing denying that worries and stresses are a part of life but unless situations are managed properly anxiety can reach intolerable levels and lead to increased incidence of premature births, miscarriage or lower birth weights in babies. I feel managing abusive and stressful situations is the collective responsibility of expectant mother and her support network i.e. spouse, family members, caregivers, health care providers and the society at large.
Handling drug/substance abuse is tricky in expectant mothers. Abrupt withdrawal can put the mother and the fetus through unnecessary stress. A good strategy to help drug
Qualified practitioners should encourage the mothers-to-be as well as her immediate network i.e. husband, in-laws and parents to attend consultation visits and get counseling / advice.
abusing pregnant women, their unborn children, and their families is through proper diagnosis, intervening in their addiction, and coordinating prenatal care with appropriate substance abuse treatment. Females reporting with drug addiction need a sympathetic psychiatric management and gradual reduction in dose over the course of pregnancy. Newborns need to be observed carefully as well for any evidence of withdrawal symptoms. Community support can reinforce such treatments by motivating mothers to get clean and sober so that babies are born healthier and receive proper parenting.
Family counseling is also very useful for coping with or preventing physical abuse. Qualified practitioners should encourage the mother-to-be as well as her immediate network i.e. husband, in-laws and parents to attend consultation visits and get counseling/ advice. The sessions can provide a good opportunity to educate people about harmful effects to the mother and child of abuse and ways to handle the pregnancy better. Couples can also be introduced to the advantages of child spacing and usage of contraception and its healthy impact on future pregnancies and health of children.
The doctors, the community elders, local organizations, in fact every educated individual must step forward and facilitate in raising awareness about the detrimental effects of violence and abuse and the right of women to a healthy life and safer pregnancy and delivery. A successful strategy would be to work both with the victims and perpetrators and simultaneously educate the communities. Particularly empowering females through awareness can help them realize that abusive situations result in persistent maternal stress and have implications on the pregnancy and they should consult a qualified practitioner and report the matter to concerned authorities in order to ensure their own and their children’s well-being.
A lot of times sharing pregnancy experiences with elders/friends can be emotionally relaxing as well. As they say happiness doubles and stress becomes half by sharing. I always encourage mothers-to-be to ventilate the problems out to people they trust such as the doctor, adults in the family or close friends, in order to relieve the pressure inside. Besides, simple exercise such as walking can help soothe nerves and give that extra boost of energy to the expecting mother feeling stressed.
As part of your work with women and children in prison, what challenges do you feel pose a major threat to maternal and fetal health?
Majority of women (90%) living in jails across Pakistan are under trial. No woman, especially the pregnant ones should be in jail unless they are proven guilty because health facilities are almost non-existent in female prisons. In a country which already has a dismal infant and maternal mortality rate, imprisonment jeopardizes maternal and fetal health further by deterring women from seeking prenatal care.
I have been working in the Karachi central prison since the 1980s in trying to provide access to antenatal care to mothers and health care access to their children. Even though we have succeeded in extending health coverage, drug counseling and programs to help women deal with a past of abuse and violence, there are many aspects of prison life we have no control over and which are highly detrimental to maternal health. Women in jail continuously face anxiety and stress due to over-crowdedness; ill-treatment by fellow inmates; harassment by staff; lack of privacy and separation from families. Imagine a baby coming into the world surrounded by frustrated women who could be murderers, robbers or prostitutes. The confining environment, use of obnoxious language, and abusive attitudes expose children to the worst possible upbringing. It may even result in children becoming criminals not being afraid of going to jail which they consider home. An alternate for children could be to stay with grandparents or relatives while their mothers are in jail. However, in an extremely poor society like ours, relatives make up all possible reasons they could to evade the responsibility. For instance, one of the reasons any grandmother could give for her actions is that “she would not raise a convict’s baby by herself”. In her selfishness and prejudice, she forgets about the innocence of her grandchild. It is an alarming situation and in order to improve the care of children in prison various humanitarian, health and child care organizations should work in coordination to extend assistance to mothers in caring for their children while in prison.
What characteristics do you think ought to be present in a good health care professional?
The welfare of the patient (beneficence) is central to all considerations in the patient-doctor relationship. Included in this relationship is the obligation of medical practitioners to respect the rights of patients, colleagues, and other health professionals.
Doctors and paramedics should deal honestly with patients. This includes not misrepresenting themselves through any form of communication that is untruthful, misleading, or deceptive. Furthermore, it is obligatory that a practicing doctor maintains medical competence through study, application, and enhancement of medical knowledge and skills.
Doctors also have a continuing responsibility to society and should support and participate in activities that enhance the community. As a member of society, the doctor must respect the laws of that society and be considerate of societal norms and beliefs.
Lastly, the doctors should idealize right principles, should learn to earn respect instead of building up their bank balances and should have the professional courtesy as well as empathy and compassion for the patients.
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