Pakistan International Peace & Human Rights Organization
Nindo Shaher District Badin Sindh Pakistan

The period of adolescence for Pakistani children marks an increase in a trend of gender differentials in nutrition levels and access to health care. The differentials become even more marked with the onset of adulthood, resulting in high maternal mortality rates. Intervention at this stage in life is essential not only for adolescents themselves, but also for the health of future adults.

Access to Health Care

Research conducted in Pakistan confirms a strong gender bias in access to health care. Exploring gender differentials in access to health care in the North West Frontier Province, Akhtar (1990) found that access of the female child to urbanbased health facilities was half that of the male child. The continuation of this bias has serious repercussions for the health of women, particularly adolescents and married women, whose access to services is curtailed by their low decisionmaking power in the household, limited mobility, and strict purdah (segregation of the sexes) norms.
Ahmed (1990) found, through interviews with mothers at the outpatient departments of the Islamabad Children�s Hospital, that adolescent girls faced more difficulty in accessing health care than did adolescent boys. While the boys could travel on their own to a health care facility, parents had to hire a wagon to transport a girl or else summon a doctor to their home. Both mothers and fathers felt that purdah norms interfered with the access of their adolescent girls to treatment, and that the presence of a lady doctor was essential. Ahmed found that in a rural area with a female physician present at the health center, the number of adolescent boys and girls seeking health care was roughly the same.

A small survey of adolescents in a low-income community in Karachi echoes this gender bias limiting female access to services. (Aahung 1999) Out of 80 girls ages 11-19 interviewed in-depth, 78 percent said they could not go to a doctor without permission; out of 71 boys interviewed, 32 percent said it was necessary for women in their homes to get their permission to go to the doctor.

Similar findings emerge from rural-based studies. Adolescent girls, in a qualitative survey conducted in three northern Punjab villages, complained that they only troubled their parents to go to a doctor if they were seriously ill. (Khan 1998) The mobility of unmarried girls was severely restricted by their families and communities, dramatically limiting their access to education and employment opportunities out of a fear that their honor (or chastity) would suffer as a result of contact with the public, and particularly with males. This fear is a major factor in favor of marrying girls off young, as a means to ensure that control over her sexuality is not lost. The fear of whether villagers would suspect sexual misconduct, as well as the difficulty in locating a female doctor in the vicinity, was enough to prevent girls from actively seeking health care when ill.

Kazi and Sathar (1997) found Southern Punjabi communities were more restrictive of women�s freedom of movement than the more developed villages of Central Punjab where almost half of the women can visit a health center alone. On the whole, women under age 25 were the most restricted in their freedom to go to a health center alone (only 13 percent), while 46 percent of older women could do so. Married adolescent girls, in particular, require access to the full range of health and family planning services, including information on sex and family planning, treatment for ailments associated with sexual activity, and, of course, care during pregnancy and childbearing. However, the bias against their young age restricts their access to services even when they are married.

As is demonstrated in the above studies, younger women suffer the most severe social barriers to their mobility and access to health care. Even if an adolescent girl is married, her decisionmaking power within the household is unlikely to be enough to allow her to access care when necessary. This bias poignantly captures the dilemma of being adolescent in Pakistani society, where a girl�s biological development signals her �entry into a world in which her value is largely determined by her sexual and reproductive functions� (Mensch et al. 1998). As a result, her mobility is severely restricted and her every move is scrutinized for its potential sexual suggestiveness. It is her youth that prevents her from being able to claim some of the status and increased mobility which women who are older come to enjoy after many years.

Anemia

Anemia is commonly known to affect Pakistani girls and women, weakening them during pregnancy and adding to problems of maternal morbidity and mortality. Research shows that the problem starts in childhood; it includes boys, and, in the case of girls, becomes worse as they grow older.

The last comprehensive National Nutrition Survey (NNS), in 1985-87, identified iron deficiency anemia as the most prevalent micronutrient problem in Pakistan, found in 65 percent of young children. Iron deficiency, defined in the NNS as consumption below 70 percent of the recommended intake, affected approximately 80 percent of pregnant/lactating women and 50 percent of other adult females. (Nutrition Division 1988) Over a decade later the situation has barely improved, as demonstrated by the findings of one study near Peshawar in which 90 percent of 275 surveyed children under two were anemic. (Paracha et al. 1997) The 1990-94 National Health Survey of Pakistan found that among women ages 15-44, 43-47 percent of rural women and 35-39 percent of urban women are anemic. (Pakistan Medical Research Council 1998)

A dramatic finding of the National Nutrition Survey was that among mothers the prevalence of anemia increased with age. A problem that already affected over 35 percent of the adolescents surveyed (age 15-19) seemed only to deepen with the onset of adulthood and further childbearing. This finding is a demonstration that the negative health status of adolescents is a warning of the health profile of future adults, particularly when problems such as anemia are allowed to grow more serious through lack of adequate care.

UNICEF (1998a) has identified iron deficiency anemia as one of the leading causes of Pakistan�s high maternal mortality rate, contributing to more than 20 percent of maternal deaths. In addition to maternal mortality, anemia leads to increased risk of miscarriage, stillbirth, premature birth, low birth-weight, and perinatal mortality. (Mensch et al. 1998) Factors contributing to high rates of anemia include early marriage and childbearing, short intervals between pregnancies, frequent pregnancies, poverty leading to poor nutrition, unbalanced food distribution within households, and intestinal worms. (Tinker 1998) Therefore adolescent girls, whose iron requirement will exceed that of boys as the years increase, are poised to develop a problem of iron deficiency particularly if they are poor, marry early, and have children frequently.

Anemia is as common among boys as girls in developing countries. Among girls, however, the problem does not lessen as they enter adulthood, due to iron deficiency brought on through menstruation. (Mensch et al. 1998) Table 6 shows the results from one of the only available studies of iron deficiency in Pakistani adolescents, conducted among 270 students, ages 13-20, from low-income families attending government schools in the suburbs of Islamabad. (Agha et al. 1992)

These findings indicate that while both boys and girls suffer from overall iron depletion and anemia to a similar extent, the gender differential for iron deficiency is more pronounced. Agha et al. (1992) point out that girls with iron deficiency would require iron therapy in pregnancy to avoid developing iron deficiency anemia and would not be able to donate blood without developing anemia. The problem is attributed to low dietary iron and the loss of iron due to menstruation, and the economic conditions of poverty which prevent eating foods containing iron. The pattern of anemia for boys is opposite from the development of anemia among girls, according to the National Health Survey (Pakistan Medical Research Council 1998). The highest prevalence of anemia among males is in the age group 5-14, with 47 percent of rural and 33 percent of urban boys being anemic. The prevalence of anemia in the next age groups decreases, reaching its lowest among ages 25-44, and then increases in the next older age groups. The high anemia rate among young and adolescent boys is due to their rapid muscle development, which calls for supplementation through consumption of iron-rich foods. (Kurtz et al. 1994)

Under-nutrition

The problem of under-nutrition, leading to dangerous malnutrition, has not improved in recent decades; this particularly affects infants and young children and pregnant/lactating mothers. (Kazi and Qurashi 1998) Malnutrition includes micronutrient deficiencies, such as iron-deficiency discussed above, and deficiencies in iodine and vitamin A. The latter two deficiencies not only impair the development of children, but also increase maternal mortality in impoverished regions and increase the risks of stillbirths, miscarriages, and mental retardation in infants. Malnutrition also includes protein-energy malnutrition, which is assessed by physical growth and body measurements. Gender differences in malnutrition among children under five have not been established in national surveys (UNICEF 1998a) but among adults women suffer more from malnutrition than men. (Tinker 1998)

Pregnant women in Pakistan receive only 87 percent of recommended calories and lactating women only 74 percent; their protein intake is only 85 percent of recommended levels. (Tinker 1998) Data from the National Nutrition Survey (Nutrition Division 1988) show that 34 percent of pregnant and lactating mothers were underweight compared to other women in the study, but the findings are unclear. This survey also found no apparent major restriction in types of food eaten by pregnant/lactating women and other adult females and no major difference in food intake between adult men and women.

In a comparison between schoolboys and schoolgirls (ages 6-15) food intake was equal between the sexes. But in an assessment of which percent of boys and girls (ages 6-15) were consuming below 70 percent of recommended nutrients, the results showed some gender differential, particularly in regard to the consumption of high-protein foods such as meat, fish, and eggs. (Table 7) This may be because boys are given preference within the family in the consumption of more costly highprotein foods, while girls rely more on high-calorie staple foods.

Food consumption among adolescents has not been studied in any detail in Pakistan; however, it is clear from the above data that problems of malnutrition affect both boys and girls, and become exacerbated for girls in combination with pregnancy and lactation. Further study is required to determine the proportion of pregnant/lactating women who are malnourished and to assess the extent of the problem for young women.