Who am I? Where am I? Experiences of married young women in a slum in Islamabad, Pakistan

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Who am I? Where am I? Experiences of married young women in a slum in Islamabad, Pakistan
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  BioMed   Central Page 1 of 8 (page number not for citation purposes) BMC Public Health Open Access Research article "Who am I? Where am I?" Experiences of married young women in a slum in Islamabad, Pakistan SaimaHamid* 1,2 , EvaJohansson 1,3  and BirgittaRubenson 1  Address: 1 Global Health, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden, 2 Health Services Academy, Islamabad, Pakistan and 3 Nordic School of Public Health, Gothenburg, SwedenEmail: SaimaHamid*-saima_hamid@yahoo.com; EvaJohansson-eva.johansson@phs.ki.se; BirgittaRubenson-birgitta.rubenson@ki.se* Corresponding author Abstract Background: In Pakistan, 16% of the women aged 15–19 years are married. Many get marriedshortly after they attain menarche. This study explores the preparedness for and actual experiencesof married life (inter-spousal relationship, sexual activity and pregnancy) among adolescent women. Methods: Among married adolescent women residing in a slum of Islamabad ten were selectedwith the help of a community health worker and interviewed qualitatively till saturation wasreached. They were interviewed three times at different occasions. Narrative structuring was usedto explore how the participants represented their background, social situation, decision making andspousal communication and how they explained, understood and managed married life and borechildren. Results: Two categories identifying the respondents as either submissive-accepting or submissive-victims emerged. The married young women who belonged to the accepting group lived undercompromised conditions but described themselves as satisfied with their situation. They wereolder than the other group identifying themselves as victims. However, none of the respondentsfelt prepared for marriage. Women belonging to the victimized group experienced physical andverbal abuse for their inability to cope with the duties of a wife, caretaker of the home and bearerof children. Their situation was compounded by the power dynamics within the household. Conclusion: Knowledge about sexuality could prepare them better for the future life and givethem more control of their fertility. Adolescent development and life skills education need to beaddressed at a national level. There is need for innovative interventions to reach out and providesupport to young women in disadvantaged homes. Background One in six adolescents aged 15–19 years is married inPakistan [1]. Marriage takes place shortly after menarche. Women, who marry, move from their familiar home tothe home of the husband. They initiate sexual activity  with a husband they barely know, and soon becomemothers. Many find themselves socially isolated and withpoor inter-spousal communication [2,3]. Adolescent mar- riages lead to early pregnancies and complications due toimmaturity contributing to their vulnerability [4]. Published: 28 July 2009 BMC Public Health  2009, 9 :265doi:10.1186/1471-2458-9-265Received: 16 April 2009Accepted: 28 July 2009This article is available from: http://www.biomedcentral.com/1471-2458/9/265© 2009 Hamid et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the srcinal work is properly cited.  BMC Public Health  2009, 9 :265http://www.biomedcentral.com/1471-2458/9/265Page 2 of 8 (page number not for citation purposes) In the Pakistani context, importance is given to preserving the chastity of young women before marriage. Their sexu-ality is tightly controlled by their guardians [5]. Seclusionnorms ( purdah ) are common from puberty onwards andunmarried women have restricted mobility [6]. As discus-sions of sexuality are discouraged little is known about sexual attitudes and behaviour of young people in Paki-stan [5]. Many young women are poorly informed about sexual issues, reproductive biology and health [7,8]. Low  levels of school attendance, lack of sex education andnorms that prohibit discussion of sexual issues preserveignorance [6,9,10]. Men are relatively more knowledgea- ble about puberty, pregnancy, family planning and sexu-ally transmitted infections [11]. Adolescence is a period of significant change and transi-tion towards social and economic independence. Boysand girls make important choices and build critical capac-ities during this period [12-14]. Entering into marriage adds to the complexity of the situation for young womenin Pakistan [15]. History and environment jointly influ-ence the value systems and norms of a society, whichinclude settlement patterns, household structure and divi-sion of labour. Aspects of adult personality are culturally expressed and projected in rituals and belief systems e.g.reflected in women's limited control over their own lives[16,17]. Men have access to a variety of information sources outside home while young women are restrictedto a limited number [15]. Gaining information is event based, whereby specific events e.g. puberty and marriagetrigger information provision to young people, however often too late to be educative.Limited research is available on factors that shape themarried adolescent women's reproductive behaviours andexperiences. A study conducted in Bangladesh [18] onmarried adolescent women showed that many had bornechildren before they were emotionally and physically ready. Poverty, economic conditions, marital insecurity,politics in the household, absence of dowry and rivalry among family, co-wives and in-laws made these young  women comply to decisions made by others in order tosurvive. They had been compelled to bear children or ter-minate them subject to the decisions of others in thehousehold. The objective of this study is to explore how young  women (13–19 years) are prepared for married life. It explores their experiences and knowledge of married lifein relation to sexual activity, child birth and inter-spousalrelationship. Methods  A qualitative approach was used to explore experiencesrelated to married life and to examine the relationshipsbetween different social levels inspired by Bronfenbren-ner's ecological framework [19]. According to Bronfen-brenner, individuals are nested in environments or systems (terms used interchangeably), each of which iscontained in the other, from more proximate to more dis-tal determinants. All of the systems are interdependent and interactive, with changes in one system affecting theother systems. This human ecological framework permitsexamination of linkages between levels of environmentalcontext. This ecological approach relates changes in theindividual to the social and physical environment [19]. The research team comprised of a Pakistani medical doc-tor with a public health focus (PI), a Swedish public health expert, a Swedish nurse with a focus on childhoodtransition and rights, and a Pakistani community worker as a gate keeper. This broad composition of the researchteam brought different perspectives to the study. The com-munity worker played a key role in giving the emic per-spective to the study. She met women residing in thecommunity regularly and was an advisor for health andsocial issues.She shared her insight of the culture and norms of thecommunity under study with the PI. The interviewing wasdone by the PI followed by data interpretation and analy-sis together with the rest of the research team members. The outsider's view of the Swedish scientists broadenedand enriched the understanding of the material. Setting   The study was conducted in a slum community in the out-skirts of Islamabad city. There were 900 houses in thecommunity and almost 400 households had more thanone family living in one house. Most of the residents werelabourers working on daily wages. Most residents wereilliterate belonging to the low socio-economic group withpoor hygiene and nutritional status. They belonged to dif-ferent ethnic groups in-migrating from different areas of Pakistan. Living together they had adjusted to each other and developed a common culture. The women had usu-ally not attended school beyond primary level and many had never even begun. Shortly after puberty they weremarried and moved to live with the in-laws for culturaland financial reasons. Most women had limited opportu-nities for employment and education. There was one sew-ing school run by an NGO where those who could affordattended classes. Going outside of the house required anelder from the house to accompany them. Participants and Data Collection  Through purposive sampling married adolescent women who were willing to share their experiences wereapproached by the community worker. If one refused,another participant fulfilling the criteria was included in  BMC Public Health  2009, 9 :265http://www.biomedcentral.com/1471-2458/9/265Page 3 of 8 (page number not for citation purposes) the sample. Thus ten participants were interviewed by thePI. Multiple meetings with the participants were held sothat the researcher developed rapport with the partici-pants. The interviews were conducted in private, with nofamily member or the community worker around. Thishelped break the ice and gave the participants a chance tore-think past events and remember other associated expe-riences that could be shared at subsequent meetings.Unstructured qualitative interviews [20] were chosen asthe appropriate method. A married life calendar was developed to explore the expe-riences of the participants by discussing their needs at thetime of marriage, their access to information, source of information prior to marriage and the experience of sex-ual activity, communication with their husbands andchildbirth. The interviews were tape recorded with the participants'consent and transcribed within two days by the PI. Theresearcher went back with the written narration for verifi-cation followed by any further probing identified asneeded by the research team. Data Analysis  The complete transcripts were read several times to gain ageneral sense of the experiences of the participants. Bron-fenbrenner's model was kept in mind when exploring how the different systems affected the young women and what the linkages were between them. The interviews werecompared and themes and events searched for whichcould explain the experiences of the women and the way they identified themselves. Narrative structuring was usedto demonstrate how the participants described their back-ground, social situation, decision making, spousal com-munication and how they explained, understood andmanaged married life and bore children. Narratives arenot the exact records of what actually happened [21]. Thehistorical truth of the participants' account is not the pri-mary issue. Narrativisation is the point of view of the indi- vidual based on his/her experiences and interpretation[21]. The same event is narrated differently depending onthe values and interests of the narrator and to whom thestory is told. As the past is selectively reconstructed trou-bling events will be recalled and narrated differently.Researchers have to assess whether the account of theevents are persuasive and plausible [21]. Through theprocess of "narrative finding and narrative creating" [20]two main thematic narratives were developed depicting the two main identities found in the stories of the partici-pating women. The perspectives of the different researchers in the teamenhanced the trustworthiness. Combining the insider andoutsider perspective contributed to the understanding of the material. The findings were discussed with the com-munity worker for verification. Ethical Considerations Ethical clearance for the study was sought from thenational research body (Pakistan Medical Research Coun-cil) and from the ethical committee of Karolinska Insti-tutet, the medical university of Stockholm in Sweden.Before starting the interviews the study was introduced tothe community. Verbal consent from all the participants was obtained prior to their participation in the study. Thestudy was explained and queries addressed before the start of the interviewing. The consent of the participants wasobtained after the permission from the decision maker inthe house had been given. In most cases it was the mother-in-law in the absence of the husband. The consent state-ment was read out clearly explaining the study objectivesand the expectations on the study participants to facilitatetheir understanding. Study participants were assured of confidentiality. The study could raise reactions and emo-tions difficult for the participants to handle and the com-munity worker was asked to be available for those whoneeded extra support and comforting and to facilitatereferral through the NGO if needed. Results  The participants with their individual socio-demographic characteristics are presented in Table 1. Major topicsreflective of the personal narratives include the following categories: (a) family network and its influences on deci-sion regarding marriage, (b) puberty and menstruation,(c) preparation for marriage (dowry, relationship with thenew family members), (d) sexual activity (e) contracep-tion and child-birth (f) role of the husband and other family members, (g) future aspirations and expectations. The following section is based on the stories of all the par-ticipants from which two thematic narratives were devel-oped. They include selected verbatim quotes from someof the participants that illustrate experiences common tothem. Themes helped to focus on the different parts or fac-ets of the stories and served to compare participants' sto-ries and illustrate the similarities and differences. Throughdeliberations and discussions the participants could besorted into the following two groups: the submissive-accepting and the submissive-victims. Pseudonyms areused to protect the identities of the participants. All the participants expressed their need for better prepa-ration before marriage. The young adolescent women viewed marriage as the end of their childhood and wereoverwhelmed by the responsibilities that they wereexpected to fulfil after marriage. They were not preparedfor initiation of sexual activity. None of the participantsknew that sexual activity leads to conception.  BMC Public Health  2009, 9 :265http://www.biomedcentral.com/1471-2458/9/265Page 4 of 8 (page number not for citation purposes) NARRATIVE 1 Submissive and Accepting  My name is Shakira (Thankful) and I am 20 years old. Igot married two years ago to my first cousin who is twenty four years old. He is a painter and has completed ten yearsat school. We live in a joint family system with my par-ents-in-law and my husband's married brothers and their families. I attended school for five years but when my father could not take me to school I dropped out.I was engaged at birth and wore a string around my wrist.My aunt would refer to me as hers but I never understood why. Before my "nikkah" (legal marriage) at 14 years of age I menstruated two to three times. I had learnt about it in school and since I was close to my mother, she told methat it was normal and I was to have them monthly for fiveto seven days. She said I was no longer a child and shouldcover myself properly. She told me I had to be responsibleas I was going to be married soon. I did not talk to my hus-band before marriage.No one prepared me for the physical relationship I was tohave with my husband. After three days of marriage Iguess someone must have talked to him. That night hegave me 1000 rupees. He said that we had to start lifetogether. I understood what he wanted, a woman knows. You age overnight the day you are labelled married. I wasshocked by my experience, felt as if something bad hadhappened. My husband felt guilty for giving me pain. Thenext day I expressed my shock to my mother. She simply replied, "This happens!" It took me 15 days to settledown. I had my periods once after marriage and then Iconceived. It would have been easier if my mother hadprepared me for the physical relationship with my hus-band. I had married friends who talked but I never really understood the meaning of marriage. I did not know that sexual activity would lead to conception. I missed my periods and mentioned it to my sister-in-law who told my mother-in-law and my mother. Both were thrilled. Seeing my confusion my mother told me that when I was bornshe had the same problem implying that I was going tohave a baby. I was upset as I felt that this was too soon andI was too young to have a baby.My pregnancy went fine. The doctor came to deliver thebaby at home. The baby was exclusively breast-fed and vaccinated. My mother came to help me after my delivery as I was weak. She taught me everything. I couldn't havemanaged without my mother's help. She would assist mein the household work. The baby was one year old whenI had my menses once. I did not know that I was pregnant till my older sister-in-law asked me to have the pregnancy test done again. A few days later I had spotting and wastaken to the doctor who told me that I had miscarried.My husband has gone to Middle East as a labourer for three years. He sends money to my father-in-law whogives me some for my expenses. I like the joint family sys- Table 1: Profile of Young Married Women NoAgeMarriage ageInformation about menstruationDecision about marriageHusband's characteristicsLiving arrangement/s 11918 Friend informed on menstruationParents25 years, 8 years schooling, shopkeeperIn parental home (narrative 1) 21917 Mother taught practicalitiesUncle20 years, 10 years schooling, employeeWith in-laws, parents in same city (narrative 1) 32019 Friend taught practicalitiesElders of the family22 years, 10 years schooling, painterWith in-laws, parents in the village (narrative 1) 42018 Mother taught practicalitiesParents21 years, 8 years schooling painterWith in-laws, parents in next street (narrative 1) 51716 Teacher taught menstruation and hygieneParents24 years, master studentIn parental home ( narrative 1) 61313 Mother taught practicalitiesMother15 years, no school, labourerWith in-laws, parents in the village (narrative 1) 71817 Grandmother and aunt taught practicalitiesFather and Aunt20 years, 5 years schooling, taxi driverWith in-laws, parents in same city (narrative 2) 81513 Sister taught practicalitiesParents and Uncle18 years, 10 years schooling, farmerIn parental home (narrative 2) 91314 Aunt taught practicalities, managed alone first timeFather and Stepmother30 years, 10 years schooling, tailorWith in-laws, parents in same city (narrative 2) 101713 Friend taught practicalitiesFather25 years, no school, shopkeeperWith siblings in parental home (narrative 2)  BMC Public Health  2009, 9 :265http://www.biomedcentral.com/1471-2458/9/265Page 5 of 8 (page number not for citation purposes) tem. My parents-in-law love me and I attend to the house-hold chores with my sister-in-law.My childhood is gone. I have entered into a responsiblelife. If I have a daughter, I will marry her at 20–25 yearsafter she has completed her studies. My husband says weshould have no more than two to three children. He hasseen his brother with his five children. My husbandbelieves in educating the children. We want to be finan-cially independent. NARRATIVE 2 Submissive and Victim I am Masooma (Innocent) and I am 15 years old. I always wanted to study and my mother encouraged me. My lifechanged when my mother died three years ago. She burnt herself to death after having a fight with my father. He pre-tended to be asleep while my mother poured kerosene oilon herself and set herself on fire. My six year old brother  watched and cried. She died three days later. Our father could not look after us. I did not know how to attend tohousehold work or cook. My mother always had told meto concentrate on my school work. For almost a year westruggled like this. When I had my first periods I thought I was going to die. I was the oldest amongst my siblings. Ihave four younger brothers. I told my father I had urinary infection and he got me some medicine. When my aunt came to visit us three days later she told me that this is part of growing up.One year later seeing the pathetic state of the house andchildren my father re-married. We were very upset and didnot like our stepmother. She told my father to wed me off and in less than a year's time I was out of the house. I cameto know of my marriage only one week before my mar-riage. I was going to school and was in class eight. I wanted to study and not leave home but my father black-mailed me into it by saying that he might die and that boys can live on their own but women need security. Itherefore obliged him by agreeing to my marriage.I found out that my husband worked as a clerk in an officeand was 16 years older than myself. I cried a lot but look  what happened. I am five months pregnant. My parents-in-law want a grandson as their other son who is marriedhas four daughters. My husband's two sisters and oneolder brother are married too. His younger brother is get-ting married next year to his cousin. My mother-in-law took me to the hospital as I was vomiting a lot at home. When I saw the nurse and the doctor scolding the patientsI was scared. I found that very insulting. I am afraid to gothere for my delivery. My mother-in-law says home deliv-eries are convenient and comfortable.My husband wants his things his way, wants the house tobe in order, parents happy and having no complaintsabout me. If he gets upset he starts beating me. I hope Ihave a son so that I am respected. When I got married I did not think that I would have a lifelike mine. My stepmother is far better than my mother-in-law. I am responsible for all household work. At first  when I would mess up my work or cooking, my mother-in-law would get upset and hit me. She would instigatemy husband and he would beat me up, too. Hit me with whatever came into his hand. My mother-in-law likes tocreate a drama.... I complained to my father but my hus-band poses to be so sweet in front of him that my ownfather does not believe me. On our wedding night hereally freaked me out. I was barely 14 years old. He gaveme a lot of pain. I was so upset. I would not let him touchme. I resisted for a couple of months. He complained tohis mother who told him to tie me up and have sexualactivity with me anyway. She said that I was very cunning and not a child. My husband complained to my father. My father and the community health worker came over andtalked to me. I felt cornered and I let nature take its toll. Istill do not find my physical relationship with my hus-band pleasant. Once I conceived I thought my husband would let me be. I thought the whole idea was to conceive, which I did but it still continues. I did not know initially that such relationship leads to childbirth but I learned thisthrough the community health worker. I thought having a child would change things in my life. I wonder if it really  will! There is constant nagging at home. My mother-in-law saysI am not innocent and my husband says that I have tolearn to be obedient and submissive. I am not allowed toleave home unaccompanied. I worry for myself. Where ismy home and who am I? Discussion  The two narratives based on the interviews of the study explain how the different levels of family, community andsociety impact on the young women's lives. The parentsby deciding about their marriage often without their involvement and consent, the parents-in-law by often tak-ing on an oppressive and demanding role and the society  with its expectation that young women be obedient, allcontribute to their submissive nature. Home Situation and Preparation for Marriage  The interviews showed that the position of young married women is very vulnerable in the low-income setting of thestudy. At the age of 13–19 years they pass from being adaughter to a daughter-in-law and wife in a new home. The limited information they had about marriage did not prepare them for what was waiting. They were raised to beobedient and not question decisions of the elders. They  were taught how to adjust in their new homes but receivedno or deficient information on or around sexuality from
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