Seven percent of all young boys are married before the legal age in Pakistan. Credit: Irfan Ahmed/IPS

By Irfan Ahmed
LAHORE, Jul 16 2014 (IPS)

At first glance, there is nothing very unusual about Muhammad Asif Umrani. A resident of Rojhan city located in Pakistan’s eastern Punjab province, he is expectantly awaiting the birth of his first child, barely a year after his wedding day.

A few minutes of conversation, however, reveal a far more complex story: Umrani is just 14 years old, preparing for fatherhood while still a child himself. His ‘wife’, now visibly pregnant, is even younger than he, though she declined to disclose her name and real age.

The young couple sees nothing out of the ordinary about their circumstances; here in the Rajanpur district of Punjab, early marriages are the norm.

Girls in rural areas are often given in marriage in order to settle disputes, or debts. Some are even ‘promised’ to a rival before they are born, making them destined to a life of servitude for their husband’s family. -- Sher Ali, a social activist in Rojhan city
Umrani’s father, a small-scale farmer, tells IPS he is “proud” to have married his son off and “brought home a daughter-in-law to serve the family.”

Similar sentiments echo all around this country of 180 million people where, according to the latest figures released by the Pakistan Demographic Health Survey (2012-2013), 35.2 percent of currently married women between 25 and 49 years of age were wed before they were 18.

According to the UNICEF Innocenti Research Centre, seven percent of all boys are married before the legal age in Pakistan.

Families like Umrani’s are either blissfully unaware of, or completely indifferent towards, domestic laws governing childhood unions.

Intazar Medhi, a lawyer based in Lahore, tells IPS that the Child Marriage Restraint Act of 1929 – which prohibits girls under the age of 16 and boys under the age of 18 from being legally wed – is one of the least invoked laws in the country.

While the Act is in force in every province, and was recently amended by the government of Sindh to increase the legal marriage age of both boys and girls to 18, it is hardly a deterrent to the deeply embedded cultural practice.

For one thing, violators are fined a maximum of 1,000 rupees (about 10 dollars), what many experts have called a “trifling sum”; and for another, the law doesn’t extend to the many thousands of ‘unofficial’ marriage ceremonies that take place around the country every day.

In a country where 97 percent of the population identifies as Muslim, few nikahs (marriage agreements under Islamic law) are registered with an official state authority.

Scores of married couples live together for years without any documentary evidence of their union, with many families preferring to avoid legal formalities.

It is thus nearly impossible for government officials to estimate just how many such ‘illegal’ unions are taking place, or to dissolve contracts that entail nothing more than the presence of a religious person and witnesses for the bride and groom.

Some advocates like Intezar believe the problem can be rectified by following the example of the Sindh province, whose amendment of the 1929 Act upped its punitive power to include a three-year non-bailable prison term and a 450-d0llar fine for offenders.

He thinks setting 16 as the official marriage age – the same age at which Pakistanis receive their Computerised National Identity Cards (CNICs) – will make it easier for law enforcement officials to take action against those responsible for marrying off young children.

The government, he says, must also take steps to ensure timely birth registrations as millions spend lifetimes without any documentary proof of their existence.

Tradition trumps law enforcement

But for Sher Ali, a social activist based in the same city as Umrani’s family, a single law will not suffice to clamp down on a centuries-old practice that serves multiple purposes within traditional Pakistani society.

For instance, he tells IPS, girls in rural areas are often given in marriage in order to settle disputes, or debts. Some are even ‘promised’ to a rival before they are born, making them destined to a life of servitude for their husband’s family.

Various tribes also have different standards for determining an appropriate marriage age. For example, Sher explained, in some regions like the Southern Punjab, a girl is deemed ready for marriage and motherhood the day she can lift a full pitcher of water and carry it on her head.

In a country where the annual per capita income hovers at close to 1,415 dollars and 63 percent of the population lives in rural areas, girls are considered a burden and cash-strapped families try to get rid of them as early as possible.

Perhaps the greatest obstacle to ending child marriages is the Council of Islamic Ideology (CII), an unofficial parliamentary advisor, which also wields tremendous power to influence public opinion.

When the Sindh government announced its plans to extend the marriage age, CII Chairman Maulana Muhammad Khan Sherani denounced the move as an effort to “please the international community [by going] against Islamic teachings and practices.”

Comprised of prominent religious scholars, the Council has repeatedly urged the parliament to refrain from setting a “minimum marriage age”. Though parliament is not legally bound to any suggestions made by the body, many allege that the extent of its political power renders any ‘advice’ a de facto order.

Indeed, repeated assertions by religious groups that puberty sanctions marriage has led to a situation in which girls between eight and 12 years, and boys in the 12-15 age bracket, find themselves husbands and wives, while their peers are still in middle-school.

Speaking to IPS over the phone from Malaysia, Dr. Javed Ahmed Ghamidi – who is known as a moderate and had to leave the country after receiving several death threats from extremists – said that since Islam does not specify an exact marriage age, it is up to the government to draft necessary laws to protect the rights of its citizens.

He fully supports the implementation of a law that only allows legal unions between people who are old enough to run a household and bring up children.

“Such laws are not at all in conflict with the teachings of the religion,” he insisted.

Qamar Naseem, programme coordinator of Blue Veins, an organisation working to eliminate child marriages, pointed out that such a law is not only a domestic duty but also an international obligation, since the United Nations Human Rights Council (UNHRC) adopted a resolution against child, early and forced marriages in 2013.

Supported by over 100 of the world body’s 193 members, the resolution recognises child marriage as a human rights violation and vows to eliminate the practice, in line with the organisation’s post-2015 global development agenda.

Various studies have documented the impact of child marriage on Pakistani society, including young girls’ increased vulnerability to medical conditions like fistula, and a massive exodus from formal education.

Experts say Pakistan has the highest school dropout rate in the world, with 35,000 pupils leaving primary education every single year, largely as a result of early marriages.

Slowly, thanks in large part to the tireless work of activists, the tide is turning, with more people becoming aware of the dangers of early marriages.

But according to Arshad Mahmood, director of advocacy and child rights governance at Save the Children-Pakistan, much more needs to be done.

He told IPS there is an urgent need for training and education of nikah registrars, police officers, members of the judiciary and media personnel at the district level in order to discourage child marriages.

Effective laws must be coupled with the necessary budgetary allocation to allow for implementation and enforcement, he added.

“People will have to be informed that child marriages are the main reason behind high maternal and newborn mortality ratios in Pakistan,” he concluded.

(END)

In Uganda, two percent of women of a reproductive age have experienced fistula, according to the Uganda Demographic Health Survey 2011. Credit: Amy Fallon/IPS

By Amy Fallon
KAMPALA
, Nov 19 2013 (IPS)

Ever since giving birth to a stillborn baby 15 years ago, Mary*, a peasant farmer from Mubende District in central Uganda, has continuously leaked urine.

“I am home all the time. I don’t go out to the market, I don’t go to church,” says the 35-year-old, speaking through a translator in a crowded ward at the Mulago National Referral Hospital in the country’s capital, Kampala.

Every time Mary drinks something, her bladder empties out the contents and she is forced to constantly pat herself dry with old clothes.

Mary has obstetric fistula. Defined as a hole between the vagina and the bladder, or between the vagina and rectum of a woman that results in the constant leakage of urine and/or faeces through the vagina. The medical condition is predominantly caused by prolonged or obstructed labour lasting more than 24 hours.

Mary’s labour lasted three days. As the nearest hospital was too far away, Mubende District is some 144 km west of Kampala, a traditional birth attendant took Mary to a small health facility when she went into labour. For 48 hours she remained there, trying to give birth to her child. On the third day she was taken to a district hospital where she was able to deliver her stillborn baby.

Abandoned by the father of her child, Mary was later ostracised by her own family.

“Even my sisters who I was living with shunned me. I am stigmatised because I smell all the time,” she tells IPS.

Mary’s story is “typical”, Dr. Susan Obore, an obstetrician who specialises in urogynaecology at the Mulago National Referral Hospital, tells IPS.

In Uganda, two percent of women of a reproductive age have experienced fistula, according to the Uganda Demographic Health Survey 2011. This means there are an estimated 140,000 to 200,000 women with fistula in the country, the Ugandan Ministry of Health (MoH) said in June.

“The true figures are not known because [women] do not come out, they are so stigmatised,” says Obore. “So what we see is probably the tip of the iceberg.”

Uganda grapples with an incredibly low number of surgeons who have the required training to carry out fistula repairs. Currently there are only 24 in this East African nation.

“Twenty-four in a population of about 34 to 37 million. It’s like a drop in the ocean,” national fistula specialist and specialist in the MoH, Peter Mukasa, tells IPS.

“Every hospital should be able to repair a woman with fistula.”

Mukasa says the country has 1,900 new cases a year and can operate on 2,000 women annually. But according to the MoH, the large backlog of fistula cases, coupled with the increasing number of new cases, has “surpassed the existing capacity of our health facilities to repair the cases.”

“We are in a static position; the backlog remains. It will take us so many years to eliminate this,” Mukasa says.

“As we speak now there’s a fistula being formed, one or two or three or four hundred women are getting obstructed (in labour).”

He says fistula repair costs on average about 400 dollars, including the cost of transport to hospital, hospitalisation and other care.

“It is a lot of money,” he concedes, adding that in Uganda the expense is mainly catered for by the United Nations Population Fund (UNFPA).

Ethiopia, where according to the World Health Organisation at least 8,000 women develop new fistulas every year, is home to the world’s first dedicated fistula hospital, the Addis Ababa Fistula Hospital. But Obore insists a similar facility is not needed in Uganda.

“We are hoping to kick out fistula, so there’s no reason why we should have a dedicated hospital,” she says.

“Empowerment of women is one of the best ways to prevent fistula,” Obore adds.

Those most vulnerable to contracting fistula are young, illiterate and rural dwellers.

Worldwide, there are over two million women in Africa, Asia and the Arab region living with untreated obstetric fistula, according to the global Campaign to End Fistula, a programme by UNFPA and various partners.

Between 50,000 and 100,000 new cases of fistula, treatable through reconstructive surgery, occur globally each year, according to UNFPA.

International NGO Uganda Village Project (UVP) run fistula repair camps three times a year at Kamuli Mission Hospital, in Kamuli, eastern Uganda. Patients are identified through radio shows, village outreach programmes, health centre referrals and by word of mouth. They are transported to hospital and operated on by surgeons from the Uganda Childbirth Injuries Fund, a United Kingdom-based organisation.

The last camp was held in early September and 15 patients had surgery. For nine of them, the surgery was successful. The remaining four women still require a second operation, which will take place during the next camp that begins on Jan. 18, says the managing director of UVP’s Iganga office, Kait Maloney.

Mary was not aware she could be operated on until she heard a radio announcement. The first surgery she had at a rural hospital was unsuccessful. She was referred to the Mulago National Referral Hospital, where she will be operated on in the coming months.

“I’m happy to have the surgery. I have no problem going for it,” she says.

But Mary says that even after she has the surgery she will still think about her fistula. She acknowledges that it is unlikely she will have another baby because of her ordeal.

*Name withheld to protect patient’s identity.

About 99 percent of patients with obstetric fistula cannot afford to pay their doctors. Credit: Jugran Bahuguna/IPS

By Zofeen Ebrahim
KARACHI, May 27 2013 (IPS)

Sherhshah Syed is a highly qualified doctor and president of the prestigious Pakistan National Forum on Women’s Health (PNFWH) but his income does not match his qualifications.

He often spends long hours treating women with obstetric fistula, a severe reproductive health condition arising during childbirth that primarily affects women and girls who have no access to even the most basic medical care.

But since fistula is considered to be “the poor woman’s” disease, few of his patients can afford to pay him for his labour.

Dr. Sajjid Ahmed, who heads a PNFWH fistula project, tells IPS with a smile, “More than 99.9 percent of (our) patients are so poor, all they can offer us in exchange for giving them a new life is gratitude and an embroidered handkerchief.”

Labelled an “entirely preventable condition” by the international medical community, fistula develops during prolonged labour, “when the baby’s head puts pressure on the lining of the birth canal and eventually (rips) through the wall of the rectum and bladder, resulting in urinary or faecal incontinence,” Syed told IPS.

Fistula also causes stillbirths, kidney failure and a perpetual faecal odour emanating from the woman’s body.

The condition is rarely found in the developed world but is common in many Asian and African countries, affecting an estimated three million women, according to the World Health Organisation (WHO).

The fact that there are no country-specific statistics available for Pakistan is indicative of the indifference and stigma that surrounds the ailment.

Syed made a “conservative” guess that anywhere between 5,000 and 6,000 women in Pakistan are suffering from the condition, which can only be treated through reconstructive surgery.

“While we are able to (treat) 1,000 women each year, there are many more who suffer silently,” he said, attributing this silence to a sense of shame, a culture that does not allow women to make decisions about their own bodies and a lack of awareness among health practitioners.

Some experts blame this on flaws in medical colleges’ curricula. Dr. Qazi M. Wasiq, general secretary of the Sindh chapter of the Pakistan Medical Association (PMA), says colleges are “out of touch” with the needs of the country and the community.

“We train our young doctors to serve in countries like the United States, the United Kingdom and the Middle East, where fistula is non-existent. Most students have only a bookish knowledge of the condition, with hardly (any awareness) of the debilitating details.”

This oversight has heavy ramifications in Pakistan, a hotbed of maternal and infant mortality. According to official statistics in the Pakistan Demographic and Health Survey of 2007, the last time such data were gathered, the maternal mortality rate (MMR) of 276 per 100,000 live births is one of the highest in the region.

In comparison, according to the WHO, the MMR is 35 in Sri Lanka, 170 in Nepal, 200 in India and 240 in Bangladesh. Many other countries in South Asia are showing signs of progress, but Pakistan’s MMR has remained virtually unchanged since 1991.

In addition, the infant mortality rate is 78 deaths per 1,000 live births; for those under five the rate is even higher, touching 94 deaths per 1,000 live births. This means one in every 11 children born in Pakistan dies before reaching his or her fifth birthday.

The vast majority of these fatalities occur in the countryside, where women have little or no access to basic care. Most qualified female gynaecologists are reluctant to take up posts in remote rural areas, particularly in provinces like Balochistan and the northwestern Khyber Pakhtunkhwa (KP), according to PMA’s Wasiq.

According a recent report by the British medical journal ‘The Lancet’, evidence-based interventions can prevent roughly 58 percent of an estimated 368,000 deaths of mothers, newborn babies and children. In addition, 49 percent of an estimated 180,000 stillbirths could be prevented by 2015.

For years, Syed and his colleagues have urged the government to invest in providing basic emergency obstetric care by deploying trained birth attendants into rural areas to advise families against early child marriage, one of the leading causes of fistula.

According to Syed, dispatching an additional 400,000 nurses, paramedics and midwives to some 80,000 villages across Pakistan would have a huge impact on maternal mortality rates.  So far, however, there only 148 schools training 28,000 midwives.

With no official monitoring of the situation, women who develop conditions like fistula have to rely on concerned relatives to take action on their condition.

Ahmed says it is always mothers, fathers and brothers who accompany fistula patients to treatment centres – rarely, if ever, do husbands or in-laws volunteer to deal with the condition.

In 2006, the PNFWH in collaboration with the United Nations Population Fund (UNFPA) started the Fistula Prevention and Treatment Project with the aim of providing free treatment services to fistula patients all over the country, and training service providers.

On May 23, the UNFPA marked the first-ever International Day to End Obstetric Fistula, with the aim of building on local efforts to raise awareness of a condition that is not “understood even in societies where it is prevalent.”

In the eight years since the UNFPA project began, 13 fistula repair centres have been set up across Pakistan, all in government hospitals; but trained doctors, who currently number about three dozen, have not increased proportionately.

Ahmed says building an adequate medical force to deal with the problem requires commitment, compassion and sensitivity without the expectation of anything in return.

“Then again,” said Syed, “not everyone is mad enough to spend hours on something that earns you prayers but no economic benefits.”

Medical practitioners tell IPS that an obstetrician’s salary in a government hospital is anywhere from 600 to 1,000 dollars per month. In comparison, those with private practices earn the same by performing just one caesarian section.

Roughly 82 percent of Afghan girls drop out of school before the sixth grade, partly due to early child marriages. Credit: Najibullah Musafer/Killid

By Abida M. Telaee
KABUL, Feb 26 2013 (IPS)

In Afghanistan, the maternal mortality rate is on the rise; hospitals are filling up with anaemic women and girls; and in over 200 districts, high schools are devoid of even a single female pupil. These issues are not unrelated – they are all products of a grave social problem in this country of 35 million people: early child marriages.

According to Sadia Fayeq Ayubi, head of the reproductive health department at the ministry of public health, early marriage (of girls younger than 16 years) is illegal in Afghanistan yet girls as young as 13 are frequently married, often to much older men.

In 2013 alone, 53 child marriages have been reported, said Nazia Faizi, a representative of the rights department at the ministry of women’s affairs.

And although that number is less than in previous years, it does not provide an accurate picture of the situation since “there are more unreported cases in the rural areas where women are more deprived and have no rights or access to legal help”, Faizi added.

Child marriages are most common in four northern provinces: Kunduz, Sarpol, Faryab and Herat, where women’s “access to justice is poor”, she said.

Girls are coerced into marrying young. Many families consider it a matter of shame if their daughter is not married by the time she is 16 years old.

Sometimes, young girls are also “traded” in marriage to save family honour or in compensation for a crime committed against a member of the family the girl is being married into.

According to Sayed Salahudin Hashimi, a preacher in Abu Bakr Siddiq Mosque in Khair Khana, Kabul, although Sharia law allows the marriage of post-pubescent girls, the decision to take a husband lies entirely with the girl herself: she cannot be forced, and she has the right to reject the offer.

But while this may be the case on paper, the reality for millions of girls is very different.

Medical concerns

Nayela, a teenager hailing from the Sarpol province in northern Afghanistan, is currently in the Malalai Maternity Hospital in the capital city of Kabul for treatment of fistula.

A serious reproductive health condition arising during childbirth, fistula is common among women and girls who receive little or no professional medical care during pregnancy and labour. One of the most common forms of the condition, obstetric fistula, is characterised by an abnormal passage between the birth canal and an internal organ like the rectum.

Both painful and humiliating, fistula leads to a host of related medical problems including incontinence, bladder infections, infertility and kidney failure.

As happens with many victims of fistula, Nayela delivered a stillborn child and sustained severe internal injuries during the process. When it became clear that her condition would linger on, her husband and mother-in-law drove her out of the house.

Her mother subsequently brought her to the hospital for treatment, which involves surgery.

Dr. Hafiza Omarkhail, head physician of the Malalai Maternity Hospital where Nayela is now awaiting treatment, identifies fistula as a “rampant female problem” here, exacerbated by childhood marriages.

Nayela’s father died when she was very young and by the time she was a teenager her grandfather had forced her to marry a 40-year-old man, for what he claimed were “financial reasons”.

Now she is suffering the consequences, along with scores of other girls battling both the pressures of early marriage as well as a weak maternal health sector.

According to Sadia Fayeq Ayubi, head of the reproductive health department at the Public Health Ministry, girls are married off between 13 and 17 years, and are often pregnant between 17 and 19 years of age.

This statistic is put in sharper perspective when viewed alongside national maternal mortality statistics: one in 50 Afghan women is likely to die of pregnancy-related causes, according to the 2010 Afghanistan Mortality Survey. The lifetime risk of pregnancy-related death is five times as high in rural areas as it is in towns and cities.

But the survey’s maternal mortality rate of 327 per 100,000 live births in the survey area — which excluded parts of the country disrupted by conflict — is significantly lower than the 1,400 per 100,000 live births assigned by United Nations agencies and the World Bank for the same year.

Meanwhile, divorce rates, suicide and self-immolation are on the rise, said Parwin Rahimi, in charge of the women’s support department at the Afghanistan Independent Human Rights Commission (AIHRC).

In 2010, former Deputy Health Minister Faizullah Kakar completed a study based on hospital reports and Health Ministry records, which showed that over 2,300 women and girls in the 15 to 40 age group attempt suicide annually.

That same year, 100 cases of self-immolation were registered at the Herat City Hospital – 76 of those women succumbed to their burns.

Experts and advocates suspect that early marriages are playing a role in pushing an increasing number of women to these desperate, often fatal, acts.

Rahimi believes it is a “legal flaw” that girls can be married as young as 16 and allowed to start a family.

Most of these teenage brides face exploitation and unimaginable violence at the hands of their husbands and in-laws. They have little access to justice, and more often than not their stories go untold.

Child marriages could also explain the high drop-out rate for girls in Afghanistan – according to the international development organisation BRAC, 82 percent of Afghan girls drop out of school before the sixth grade.

The Education Ministry says the situation is worse in rural areas, where girls rarely manage to finish school. It is estimated that 70 percent of Afghan women are illiterate.

Although most girls are resigned to their fate, some fight back.

Nineteen-year-old named Mahjooba was engaged to her cousin when she was just a child. When she refused to marry him, the family became violent.

“I had continued my studies up to Class Nine. I passed an exam for admission to nursing school. When my aunt’s family got to know, they did not want me to continue with my studies. But I did not agree with their decision. I was divorced,” she said.

The AIHRC has been pushing for the registration of marriages in court as a solution to child marriages.

*Abida M. Telaee writes for Killid, an independent Afghan media group in partnership with IPS.