SILENCE OF THE CAREGIVERS

April 21, 2019

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Composed by Rohail Safdar
Composed by Rohail Safdar

Sometimes hospital wards are like a house of horrors — no windows to breathe, nobody to talk to and nobody to allay any fears.

Ayla Aziz, 21, contracted chlamydia from her husband of 11 months; her marriage was a tale of torture and abuse, with the husband maintaining multiple partners at a time. When Ayla returned to her parents’ house in Lahore, she bore a bruised eye from the physical abuse and was experiencing abnormal pain when urinating.

Accompanied by the mother, Ayla went to a gynaecologist in one of Lahore’s largest government hospitals. Although the doctor remained mum at first, nurses began asking her uncomfortable, invasive questions.

Taboos surrounding sexual health mean many women are reluctant to ask for the information and medical care they need. But equally complicit are doctors who do nothing to reduce the virtual torture of ob-gyn ward visits

“One quipped, ‘Is the black eye because of the infection or is the infection because of the black eye?’” narrates Ayla. “Another said young girls like you should enjoy sex, did you not like it? I ignored them at first because the nurses had started off with cursing my ex-husband. But then the gynaecologist herself spoke up and said I probably have had multiple partners by now and so it was understandable that I had an STD.”

Ayla has not been to an OB-GYN ward ever since.

HOUSE OF HORRORS

The obstetrics and gynaecology (OB-GYN) ward is no sanctuary. And no other moment captures this more when a woman is admitted for childbirth. In those moments, it is a play of power — by hospitals eager to admit patients by citing urgency, by doctors’ preference for caesarean births, and by attendants exerting their decisions over medical advice.

Her reliance on others increases manifold; the others seem to assume that a woman loses her sense of rational thought inside the OB-GYN ward. There is an erasure of age and of experience; she is now a child who shall be directed into giving birth. She is expected to hand over her good sense to others, including novice doctors, nurses and even distant family, when the only two people to decide her fate ought to be she and her doctor. A common thread linking the performance of these various levels of power is how a woman’s agency and voice vanish into thin air.

“My doctor had barred a particular injection because it was causing an adverse reaction to something,” says Lahore-based Rehana of the day of her delivery. “She went away for a while and, in the meantime, I started struggling with immense pain. The nurse picked up the same medicine to inject and, when I protested and said the doctors had disallowed it, she simply ignored me and went ahead anyway. Thankfully the doctor arrived just in time.”

Another woman from Peshawar, Zehra, now in her 40s, recalls her horrific experience at one of Peshawar’s renowned hospitals: “The nurses’ attitude was rather haughty. Their behaviour was very harsh and there was lots of loose talk. Whenever a woman writhing in pain called for attention, they’d snidely remark, ‘You all love having intercourse but when it’s time to have babies, you feel so much pain.’” These jibes were the extent of the medical help provided.

A huge part of the why the OB-GYN ward is a house of horrors [see stories on Page 2] is about how information about a woman’s body and well-being becomes privileged information — to the extent of the woman herself being deprived of that information.

Most doctors want to get done in a 30-minute-long operation. This is a matter of money: doctors can only deliver five or six babies in a day through vaginal deliveries but when it comes to C-sections, they can deliver between 15 and 20. C-sections save time and bring in more money they earn far more money than they would for regular deliveries.”Dr Uzma Shah | Hyderabad

Access to healthcare is yet not a reality for everyone and, even for those who can afford private healthcare, gendered norms often force women into a lack of awareness, guilt, moral judgments and character assassination. This is especially true for young women who decide to approach healthcare professionals on their own — not just for pregnancy-related affairs but also about personal sexual health.

Aasia Ali, a 28-year-old development sector professional, went to a gynaecologist with inflammation in her urinary tract. She initially contacted her friend who had graduated from medical school; the friend advised her to apply an ointment first. When that didn’t work, she recommended a tube, which had to be inserted inside her for the medicated liquid to be released. When that didn’t work either, she went to a gynaecologist at a private hospital. It turned out to be a yeast infection.

“I kept asking her how was it caused but she did not give me a convincing answer,” narrates Aasia. “She simply looked at me judgmentally and I kept musing out loud about whether it was because I did not change my pad on time or whether I used a dirty washroom. But she barely looked up at me and made no effort to explain anything.”

Aasia then went on to tell her that although she was a virgin, she and her fiancé had tried to fool around a little. She also told the gynaecologist that she had used a certain kind of tube that her friend had suggested.

“Upon hearing this she snapped and said, ‘What? We don’t recommend that to unmarried girls’ and continued to make me feel uncomfortable after she realised I was unmarried and trying to experiment with my fiancé’.”

DEMONISING SEXUAL WELLBEING

Where knowledge ought to enlighten and broaden perspectives, it seems medical education in Pakistan is still confined by the mores of virtue and shame. The attitude in a large part of the medical community is extremely conservative — moral values and ethics taught in colleges often get repeated in practice across hospitals in Pakistan.

The provision of sexual education in the country seems to be an unfulfilled dream in the foreseeable future, as most people perceive sexual education to be an encouragement for young people to become sexually active. Unfortunately, as a result of this, sexual health suffers, particularly among women who have lesser access to healthcare and low levels of mobility. In addition to this, a woman who questions anything about her sexuality is considered to be bypassing the prescribed boundaries of honour and ‘haya’ [shame] that are considered a requirement for her to command basic respect.

Young medical graduates’ medical advice is often tied up with notions of shame — often to the detriment of the patient. Information isn’t passed on and critical knowledge is often compressed into two or three words. Many doctors today are simply not equipped to talk to their patients to explain what is going on and to answer any queries.

Dr Shazia Sharaf, a practicing gynaecologist in Islamabad, agrees with the notion that it is the doctor’s responsibility as a person in a privileged position, to help people understand what they are going through.

“A lot of times they are not able to find the right words when explaining their problem,” says Dr Shazia. “For instance, if I can guess that my patient is sexually active or might have had multiple sexual partners, it is my job to ask them and ensure they are using protection etc, all the while making sure that they are feeling safe. I ask them in a way that they don’t feel judged or scared. The responsibility falls on the doctor to make that call, how to ask and what words to choose.”

Even in situations where the doctor ought to have known better, the case is often complicated by the doctor simply not communicating with the patient. Most women interviewed for this story related that they have had to ask for specific details about their case rather than doctors explaining progress on the case as routine practice. The most common doctors’ response is a word or two — “normal” — before moving on.

Many also assume that a patient’s history is the same as routine. Very few seem to look into other ailments that could inform treatment. Even fewer take the woman’s consent as a necessity.

Shazia Zubair is mother to three. Like most parents, she is exhausted by the end of the day. Unlike most parents, however, it isn’t the parenting that drains her but excruciating pain in her joints. “I was 19 when I conceived my first baby,” she narrates. “But I also had a history of arthritis. The doctor simply did not educate me about the kinds of side-effects an epidural could have. Now, after three children, doctors tell me that this excruciating pain in my joints is because of the epidurals administered to me.”

The doctor left post-operation procedures to junior staff. Fifteen days later, I returned to the hospital because bleeding hadn’t stopped. I was sent home without any explanation from the doctors. Another 15 days passed and I felt the same painful bleeding. My sister rushed me to another facility where doctors explained to us that my uterus had gotten severely infected.” Salma S | Karachi

The downright abuse meted out in many OB-GYN wards simply reinforces the fear that women have of discovering their bodies and about their sexual wellbeing. Many women shy away because the pressure of being judged and made to feel guilty about maintaining their sexual wellbeing is too much. Dr Shazia is also cognizant that it takes a lot of guts in the first place to actually come up to the doctor with a problem. There are thousands who can’t even take that step.

“In fact, men are more at risk,” she explains. “Women end up going to a gynaecologist anyway at least after getting married. Men aren’t forced to, so they end up asking their friends or looking at the internet. This way they get misguided.”

According to her, shyness towards talking about a problem related to one’s sexual health is at the heart of the spread of related diseases and disorders.

“Even if a problem exists, most people keep it a secret until it becomes a big problem,” she says. “For something as small as a breast lump, women sometimes take two years till they go to a doctor because they are just not comfortable with someone feeling their breasts. They harbour fears as though they will get character assassinated and will be asked difficult questions. It is a basic human right, I think, to have access to this kind of care.”

The demonizing of sexual wellbeing means, in turn, that people don’t understand what pleasure is.

“If I get 100 patients, almost 40 wouldn’t know about what a female orgasm is,” narrates Dr Shazia, explaining that this is an issue particular to both men and women. “It was much worse 10 years ago.”

When 27-year-old Sarah Farooq got married to her college sweetheart, she knew she was entering uncharted waters. Sex was something she had only heard about in movies or in hushed conversations with friends, oftentimes accompanied by giggles and coy smiles. “When you get married, you’ll understand,” was the common retort to any serious enquiry. The more she asked around, the greater were the aspersions cast on her: was she even of ‘good’ character?

But Sarah, a college-educated working professional in finance, and her husband were virgins when they got married and were now learning about each other’s bodies. She was having trouble experiencing an orgasm. Frustrated by the nonchalance with which her questions were being brushed aside, she decided to share her predicament with her gynaecologist — one of Karachi’s renowned gynaecologists with a booming private practice. Sarah was in for a rude awakening.

“I asked her while she was prescribing some contraceptive pills to me,” she narrates, “that I don’t feel anything when I have sex, and she snapped at me with a judgmental look saying, ‘Kya feel karna chaah rahien hain aap! [What do you want to feel!]. I cringed, as if I was asking for something wrong, something superfluous and more like, ‘How dare I demand to feel pleasure as a woman!’”

THE STIGMA OF STDS

Mahjabeen Anwar, a 26-year-old marketing professional, booked an appointment with one of Karachi’s renowned gynaecologists at one of the city’s biggest hospitals. At the counter of the OB-GYN ward, however, the attendant demanded to see the patient’s husband because the complaint was of “a sexual nature”. Mahjabeen discovered later on that the high-end hospital practised an unsaid policy of discouraging unwed women from seeking treatment at their facility.

But according to Dr Shazia, sexually transmitted diseases (STDs) and sexually transmitted infections (STIs) are more common than is commonly believed.

“If I treat 10 patients today, I can safely say six were suffering with some kind of STD,” says Dr Shazia. “We guide them with condoms and other forms of protection in addition to treatment.”

She adds that discharges, abdominal pains and urinary tract inflammations are the most common problems she has to deal with. All of these can be symptoms of STDs. The HPV virus, which can be spread sexually as well, in addition to simple contact, is a direct cause of cervical cancer. It is the second most common cancer among women after breast cancer and it can be prevented with just one vaccine once in a lifetime.

MIRROR OF SOCIETY

The words sex and sexuality are not used in everyday conversation and most Pakistanis grow up being comfortable only with euphemisms. This perpetuates taboos, and conversations around subjects such as sexual wellbeing are extremely limited. When people grow into adults, and become sexually active, either through marriage or outside of it, it is up to them to figure out everything on their own.

The OB-GYN ward, for many young women, is where help is available.

Only that it’s not.

The OB-GYN ward is a place of unfettered moral judgement, from the clothing choices a woman makes to how she sits down even when writhing in pain, from the leery glance of the ward’s chowkidars to the doctor’s assessment of whether she can afford expensive medication, a woman is under someone’s glare at all times. Not all women head to the OB-GYN ward for pregnancy issues; how dare she be here without a chaperone?

“I don’t think I have ever been shamed for not bringing a man along as much as I was at the high-end hospital,” says Mahjabeen. “I am usually perfectly comfortable with my choices but that experience made me doubt myself in a way that I had never thought was possible.”

“I don’t think gynae wards ease the process for mothers-to-be,” says Sabeen Rasheed, mother to three. “My mother was in charge of my first delivery but the rest of what happened is a blur to me. My second one was directed by doctors since my mother had passed away by then. It was only during my third pregnancy that I could put my foot down and tell my doctor what I needed and what I didn’t.”

Shanel Khaliq is a lecturer at Iqra University, Islamabad
Rabia Bugti is a freelance multimedia journalist based in Karachi


‘MY SON’S BRAIN FUNCTION IS IMPAIRED BECAUSE HE WAS DENIED OXYGEN’

Zia Baloch | Quetta

“I took my wife regularly to a renowned hospital in Quetta for check-ups. They had already declared that it will be a caesarean baby and had set a date for the operation. My sister suggested that we also seek a second opinion [about whether an operation is needed or not].

We went to another hospital where doctors said that there was still a month to go. Confused about this advice, we went to a third doctor at another private facility. She said there were another 15 to 20 days to go. And at yet another, doctors suggested that we return after four or five days as it was nearly time.

When we returned to the original gynaecologist, she declared that it was already time and that my wife needed to be admitted. We listened to her. They started inducing labour around 9am and waited till Maghrib prayers. Then they operated on my wife.

My son Zurain was born but he needed oxygen to survive. The hospital did not have any oxygen. So I had to rush to hospitals across the city to admit my newborn to a place that could take care of him. Finally a medical facility run by an international NGO took us in. If my son is alive today, it is because of them. He stayed hospitalised for 40 days there and then he was brought to Karachi and admitted at a renowned hospital.

It has been six years since then. And I have been trying to have my son treated. Recently doctors have told me that he has a maximum of 12 years to live.

His brain function is impaired because he was denied oxygen in the gynae ward."


HARASSMENT IN THE WARD

Rabia Z | Karachi

“After my operation, two attendants arrived to shift me to my room. One was at the foot of the bed and the other one next to my face. And he kept pushing his crotch to touch my body somehow. He knew this woman was probably half-dead, half-alive. She won’t say anything. But I had the strength to turn my face away and that’s what I did."


‘THE DOCTOR DIDN’T COME FOR THE OPERATION, SHE CAME THE NEXT DAY’

Afreen A | Karachi

“The date given to me when I was carrying my elder daughter was 10 days ahead. When my labour pains started, I ignored it for a while but then they became intolerable.

My husband rushed home from work that day and insisted I go to the gynae ward.

By the time I was rushed to the hospital, I had already started bleeding profusely. At home, I wasn’t able to comprehend that it was almost time while everybody around me also reassured me that it was just regular pregnancy pain.

When we got to the hospital, I was drained of all strength. I couldn’t walk. I couldn’t even move out of the car and so my husband had to bring a wheelchair to carry me inside.

I remember clearly that I was fast losing consciousness.

When they took me inside the ward, there is a limit beyond which gents are not allowed. That is where my husband was stopped and barred from accompanying me, even though he was supposed to.

There were these young duty doctors, they saw me, looked into my eyes, and said I am dying.

They claimed that the case had gone all wrong. They weren’t ready to do their job because they said blame for anything going wrong would fall on them. Eventually they took me in with my husband yelling in their ear.

My gynae­cologist, although she was on call, did not come to the hospital. She explained to the duty doctors what needed to be done, which they did. It was a normal delivery, not even a caesarean.

But the doctor didn’t come — neither when she was first informed that I had arrived, not while I was waiting, and not when my baby was coming. She came the next day and started scolding me for not having come to the hospital earlier and for creating this chaos. I did not say anything back to her.”


‘SITTING IN A WHEELCHAIR WITH INTENSE CONTRACTIONS, I WAS LEFT ABANDONED’

Huma B | Karachi

“The year was 2010. I was overdue but the doctor had assured me that both my baby and I were healthy. She asked me to come to the hospital so she could induce labour and deliver the child. She said it was likely going to be a regular delivery because the foetal position of the baby was ideal as well. I decided to listen to the doctor’s advice.

They called me late at night to induce labour. The doctor went home and she was only going to return in the morning, leaving a junior doctor in charge and an attendant by my side.

That same night, apart from the labour pains, I also had an upset stomach because of the side-effects of some medicine they had administered. When I’d ask the aaya [attendant] to help me to the toilet, she’d simply refuse and say, ‘Let me sleep.’ If I protested, she’d say, ‘Bibi shor mat machao, dimaagh kharaab nahin karo. [Don’t make noise, don’t bother me].’ Because I was young and this was my first experience, I was shy and did not want retaliate or complain to anyone. Even if I wanted to, I was scared of the aaya becoming rude or misbehaving.

Throughout the night, I suffered in silence. Early morning, the young doctor checked up on me and said that I was ready to deliver. Then came the senior gynaecologist, my doctor, who told the junior that it was impossible for me to deliver normally because my case was very complicated. The young doctor replied that she felt that I was ready to deliver normally because nothing seemed to be off and once my contractions increased, the baby would come. But the senior insisted that it was only going to be caesarean baby and that was that. The junior shut up.

They put me in a wheel chair and parked it outside the operation theatre. And then the staff disappeared. Sitting in a wheelchair with intense contractions, I was left abandoned. I had started losing consciousness when other patients in the waiting area started making noise that this woman is very unwell and needs help. For 45 minutes, I was sitting in the middle of ordinary patients, men and women, around me, with no help at hand.

The surgery went well, thankfully. But I still don’t know who was in the right: my gynaecologist or her junior associate.”


‘I WAS HANDED OFF TO A MALE DOCTOR WITHOUT MY CONSENT’

K Baloch | Lahore

“The year was 2017. My first daughter was a caesarean but I wanted my second-born to be a regular delivery. I was seeing a doctor in Lahore and I had conveyed my wish to her. She also seemed willing to go by it. One night, around my due date, my water burst. I went to the hospital early morning and ran into a doctor in the

OPD. The experience with her was so distressing that I was scared of what was going to happen next.

This doctor was misbehaving with every patient who had come to see her. One woman said to her that the medicines prescribed were not available at pharmacies and to prescribe her medicines that were easily available in the market. The doctor simply kicked her out of the ward. Once the woman left, the doctor proclaimed that women patients had lost it because they are getting free medicines. By the time my turn came, this doctor scolded me for having waited the night out. She said that I needed to be admitted immediately. I agreed.

The hospital staff then took me to the labour room. One doctor said that since my water had broken, my child was now in danger of dying because she was short of oxygen. Another came in and said that since I wanted a normal birth, they are going to wait and see if that’s possible. I had gone at nine in the morning and this observation period carried on into the night.

I had figured out by then that since the labour pains hadn’t increased, it was going to be caesarean again. But I wasn’t being shifted to the operation theatre because it was busy. My gynaecologist had been carrying out one operation after the other since morning. By the time my turn came, she went home.

Now, they tried to have another senior doctor operate on me but she refused, saying that this woman isn’t my patient. Eventually a junior woman doctor and a junior man doctor took up my case. Although the delivery went well, there was a huge problem. This is an Islamic country and there are certain social norms. Women don’t go to male gynaecologists because they don’t want to show them their private body parts. But in my case, I was handed off to a male doctor without my consent.”

Published in Dawn, EOS, April 21st, 2019