by Ayesha Azeem, December 19, 2022
One of the most significant events in a woman’s life is when she goes through her first pregnancy, an experience that changes her life forever. This experience can be further complicated by one’s culture and its respective social norms that may affect women negatively. I interviewed Mary [pseudonym given to protect her identity] in both English and Urdu about her experiences with pregnancy and the healthcare she received during all three of her pregnancies, one of which was experienced in her home country, Pakistan. Mary was only 22 years old when she got married and found out she was pregnant soon after. When asked about how she felt when she found out about her pregnancy, Mary described how little she knew about morning sickness, and because at-home pregnancy tests are not easily accessible in Pakistan, Mary had to make a doctor’s appointment to confirm her pregnancy. Mary describes the first emotions she felt after hearing the news as being excited and nervous: she was excited to have her first child and finally start the family she always dreamed of, and nervous because she truly did not know what to expect. However, Mary’s experiences with pregnancy arose in less-than-ideal circumstances that proved to make the duration of pregnancy very difficult for her: while Mary was living in Pakistan with her in-laws, her husband was in the United States, working two jobs to support his new family, his brothers, and his mother. Thus, Mary was understandably terrified when she heard that she was pregnant: she did not expect to have to live through this without her husband by her side. While Mary recounts her mother-in-law taking very good care of her – accompanying her to doctor’s visits, supervising her diet to ensure that Mary received the nutrients necessary for a pregnant woman, and preventing her from completing any household chores – she did not feel adequately prepared or supported without her husband.
Lack of Knowledge About Pregnancy
Mary describes her experiences with prenatal care in Pakistan as disastrous. There was very little communication from the doctor; Mary would have monthly ultrasounds, would be told that her baby is breathing, and receive an injection at the end of every visit to “help with weakness.” Mary explains that the injection was very painful and was something she didn’t truly understand, as all of her questions would go unanswered during the visit. Unfortunately, Mary had very little knowledge of reproductive health and pregnancy; when she first experienced morning sickness, she thought she had food poisoning, and did not realize she was pregnant until she went to the doctor. Mary also did not know how to take care of herself during her pregnancy, as no one had told her that intense exercise was ill-advised. Mary recounts playing cricket with her cousins one day when she started bleeding from her vagina. Rather than panicking and rushing to the hospital, Mary simply assumed that her period had begun; it was not until she had asked her mother-in-law for a pad that Mary realized the severity of the situation. Thankfully, her mother-in-law’s quick judgement saved Mary’s fetus from further harm.
Unfortunately, the education system and healthcare system had failed Mary so horribly that she had never learned about the birthing process until the actual day of her delivery – she spent this day in a panic, trying to figure out how she would survive. After Mary had given birth, the obstetrician had unknowingly left a dangerous blood clot unaccounted for in Mary’s cervix, leaving Mary with excessive bleeding. The obstetrician removed the clot after a week via an emergency operation, but while the physical symptoms were removed, this event effectively scarred Mary psychologically.
Following the birth of her first child, Mary fell into a deep depression. This was not postpartum depression, but instead due to the almost instantaneous change in her mother-in-law’s behavior once her grandson was born. Previously very caring, Mary’s mother-in-law’s attitude toward her was now unwaveringly cold. She became very cruel, constantly hurling verbal abuse and treating her like a common housemaid rather than the wife to her oldest son.
Arrival to the United States
When Mary arrived in the United States, she expected that things would change drastically in her life and reproductive experiences. Mary hoped that she would now receive the supportive care she dreamed of from her husband. However, her expectations were never met. Mary’s husband was far from living the American dream, working long evening shifts as a taxi driver in an attempt to make ends meet for his family in America as well as abroad in Pakistan. Mary found herself more alone than ever before. Whereas she had her mother-in-law to take care of the house throughout the duration of Mary’s pregnancy, Mary now had to do everything herself during her second and third pregnancies. Not only did she have to cook food and maintain the house, but Mary also had to attend doctor’s appointments by herself as her husband was often catching up on his sleep. Whereas Mary always had her brothers and father to accompany her when she left the house, Mary now had to learn how to be independent after a life of depending on others. Without the right support from her mother-in-law, mother, or husband to help her throughout her experiences, Mary often felt lonely, and it was not long before she relapsed back into depression.
Differences in Healthcare Between the United States and Pakistan
While her personal life was exceedingly difficult, Mary found a light at the end of the tunnel: the vast difference in healthcare quality in the United States compared to Pakistan. Here, Mary found that her obstetrician was willing to listen to her complaints and work on finding solutions together, actually allowing Mary to be heard. Mary described the healthcare she received in America to be very progressive and professional; her doctors informed her of their concerns every step of the way and educated her on several things she knew nothing about, reflective of the poor health education she received in Pakistan – Mary took classes on breastfeeding, the child birthing process, and taking care of her child after birth, learning more in a few months than she had ever learned in Pakistan.
A Desire to Learn
Unfortunately, Mary’s experiences in both Pakistan and the United States are common for many women in both countries. As Mary explained in the interview, she did not have an adequate amount of knowledge regarding reproductive health and pregnancy, and thus often made mistakes in taking care of herself.
In the article titled “‘I Thought I was Dying:’ (Un)Supportive Communication Surrounding Early Menstruation Experiences,” the researchers conclude that women who menstruate hold a desire for knowledge about the health and practical information regarding menstruation, and that there is inadequate communication within close relationships regarding menstruation and reproductive health for young women (Rubinsky, Gunning, & Cooke-Jackson, 2018). The same can unfortunately be said for pregnancy; many women express a desire to know more about the pregnancy process and how they can take care of themselves.
Unfortunately, in Pakistan, there is restricted access to programs that focus on advancing knowledge on female sexuality and reproductive education. In many schools across the country, health classes cover every topic other than reproduction, because it is seen as “vulgar” to speak about such topics in a co-ed classroom. This leads young women to develop negative attitudes towards their bodies and reproductive health as they learn through social cues that their sexuality is meant to be secretive and cannot even be shared with their parents (Rubinsky, Gunning, & Cooke-Jackson, 2018). Further, women like Mary are often unprepared when they become pregnant, not knowing what to expect or how to take care of themselves. Their mothers do not provide the right knowledge to them because their own mothers never did, leading to a chain of dangerous ignorance that partially explains the high maternal mortality rate seen today in both countries.
The Treatment of Women in Pakistan
This negligence of women’s reproductive health stems from a systemic disregard for women, who are often deemed to be “inferior” in Pakistan’s society, even today. Women in Pakistan are held to different standards than men, as they are expected to compromise more in relationships, leaving their personal lives for a permanent devotion to their husband and his family. In the event of a divorce, regardless of the cause, the ex-wife is often put under intense scrutiny and is blamed for not being a “good enough wife.”
Women’s experiences with mental health, menstruation, and other aspects of reproductive health are often disregarded, and women who speak up about their trauma are carelessly labeled as overdramatic attention-seekers. These women are cast aside and deemed to be ungrateful of the many blessings they have, such as having a husband and children with no long-term medical conditions – effectively staining their reputations in response to speaking up about the trauma they have faced.
In Pakistan, women are expected to act similar to how Professor Lobel characterizes an “ideal woman” in her lecture on autoimmune disorders – suffering in silence, not asking questions, and always being compliant. Women who are vocal about the issues they face – whether it is personally or in a healthcare setting – are treated poorly for standing up for themselves.
Gender Roles and Mental Health
Further, women’s emotional experiences with pregnancy and other health concerns are often affected by the lack of support they receive from their families, especially their husbands or significant others. Like Mary, many women are expected to carry out familial duties and are part of a family system in which others depend on them. These women often prioritize the health of other family members above their own, proving to be very harmful for women who are pregnant and need to take care of themselves.
As stated in the article titled “Emotions and Mental Health During Pregnancy and Postpartum,” the strains associated with balancing work and family life with reproduction and child care are major stressors that affect women’s emotional states during pregnancy and after childbirth (Lobel & Ibrahim, 2018). In Pakistan, most women are expected to work as housewives, regardless of the amount of education they’ve had, with a lifelong commitment to caring for their children and their husbands who come home from work each day. Because of these sociocultural norms that also exist in the United States, male partners are often excused from the responsibilities that revolve around child care and household chores, even when their female partners are pregnant or otherwise unable to complete these duties. These expectations substantially prevent pregnant women from getting the rest and prenatal care they need to ensure their good health as well as their fetus’s.
The Patient-Provider Relationship
Women often receive inadequate care when they visit healthcare providers, specifically obstetricians. As Professor Marci Lobel and Lisa Rosenthal state in the article titled “Explaining Racial Disparities in Adverse Birth Outcomes: Unique Sources of Stress for Black American Women,” power plays an important role in the patient-provider relationship, and women often report feeling dissatisfied and powerless when interacting with gynecologists and obstetricians, as the medical field of reproduction is often characterized by control over women’s bodies (Rosenthal & Lobel, 2011). This is especially true for the healthcare system in Pakistan, in which physicians often dominate the patient-provider relationship and make health decisions without informing the patient and obtaining consent. As Mary stated in her interview, she would be given an injection to combat “weakness” every month with little say in the matter. The patient-provider relationship in Pakistan makes it difficult for patients, especially female patients, to vocalize their concerns about their health and receive answers to the questions they want to ask.
In addition, it is quite difficult to access quality healthcare in Pakistan, as there is no national health insurance. While there are government-funded hospitals, the care given at these facilities are often not the best and patients still have to pay fees. Private hospitals are often considered to provide the best care one can receive in Pakistan, but even at these facilities, the quality of care could be much improved. Mary described her experiences with visiting a doctor in a private practice, and recounted that even though her obstetrician had won multiple awards and was considered the best in her hometown, the care Mary received was subpar at best. This was because the doctor neglected to treat Mary as an actual human being and decided to instead take control over the decisions Mary was meant to make.
Furthermore, there are very few pharmacies in Pakistan like CVS or Walgreens in the United States that have standardized rates for medications, allowing physicians to charge patients as much as they like without much retaliation. Thus, patients often delay seeking medical care, especially obstetric care, for fear of not being able to afford all the fees associated with the visits. This delay in seeking patient care due to cost, coupled with the lack of advanced technology in Pakistan, contribute to Pakistan having one of the highest maternal mortality rates in the world.
Looking to the Future
As Mary’s experiences indicate, much work is needed to improve the healthcare experiences of women who go through pregnancy and other reproductive events in their lives, both in the United States and in Pakistan. Rather than completely medicalizing patient care, we as a society need to work to mitigate the causes that lead to the many complications women face during pregnancy and childbirth, including lack of knowledge, lack of support, and unbalanced power relationships in healthcare. Many of the sociocultural norms in both Pakistan and the United States affect the way in which women see themselves and prioritize their health, which can later affect the lives of their children. Equal treatment of women, both personally and professionally, is essential to improvements in mental and reproductive health outcomes, and can only be done when sociological efforts are made to change the way women are perceived by their loved ones as well as in public.
Rubinsky, V., Gunning, J. N., & Cooke-Jackson, A. (2020). “I thought I was dying:” (Un)supportive communication surrounding early menstruation experiences. Health communication, 35(2), 242–252. https://doi.org/10.1080/10410236.2018.1548337
Lobel, M. & Ibrahim, S.M. (2018) Emotions and mental health during pregnancy and postpartum. Women’s Reproductive Health, 5(1), 13-19. 10.1080/23293691.2018.1429378
Rosenthal, L., & Lobel, M. (2011). Explaining racial disparities in adverse birth outcomes: Unique sources of stress for Black American women. Social science & medicine (1982), 72(6), 977–983. https://doi.org/10.1016/j.socscimed.2011.01.013