COVID-19 and the Pakhtun pregnant women

Farah Naz (Department of Government and Public Policy, National University of Sciences and Technology, Islamabad, Pakistan)

Journal of Aggression, Conflict and Peace Research

ISSN: 1759-6599

Article publication date: 11 March 2022

Issue publication date: 3 January 2023

23

Abstract

Purpose

This exploratory study aims to explore the Pakhtun pregnant women’s experiences/issues during the COVID-19 pandemic.

Design/methodology/approach

This research is based on interviews.

Findings

This research found that plummeting medical services pose not only serious health risks to the Pakhtun women in Khyber Pakhtunkhwa (KP) but expose them to social and cultural challenges resulting in severe mental health issues. This study also found that the policies adopted by the Government of Pakistan for tackling COVID-19 completely threw off track basic health services that both men and women require in times of health emergencies.

Originality/value

This paper is 100% original research based on an exploratory study.

Keywords

Citation

Naz, F. (2023), "COVID-19 and the Pakhtun pregnant women", Journal of Aggression, Conflict and Peace Research, Vol. 15 No. 1, pp. 1-12. https://doi.org/10.1108/JACPR-01-2022-0662

Publisher

:

Emerald Publishing Limited

Copyright © 2022, Emerald Publishing Limited


Background

The COVID-19 pandemic has exacerbated the emotional distress resulting in the confusion pertaining to behaviors in both the personal and social domains. There is also an increase in domestic and family violence against women and girls, female health-care workers, rape, abuse and sexual harassment both at public and online spaces (UNODC, 2020). The Women’s Safety NSW report suggests that in New South Wales, Australia, more than 40% of frontline respondents experienced an increase in domestic and family violence during the lockdown phase. Here, the challenge is not dealing with sexual abuse or domestic violence itself but a situation where the victim is required to remain in lockdown with abusers (Duncan, 2020). Although COVID-19 is not the only precursor to divorce, but extended quarantine and lockdown is a significant factor in divorce and breakup/separation, because when couples spend more time being trapped at home, they expose themselves to an increased conflict and arguments. Thus, a record-high number of couples are filing for divorce in China, the USA, Australia, the UK and Europe amid the pandemic (Tocci, 2020).

The increase in adverse health and well-being outcomes for women during COVID-19 should be seen in the context where women, in general, appear to be more vulnerable because of their compromised social position. Against this background, COVID-19 left unprecedented and tormented effects on women’s health and social well-being. The lockdown may affect and have long-term negative impacts on women differently across the world (Burki, 2020).

With only the first wave, considerable research is already underway to assess the impact of COVID-19 on women’s health and well-being, especially of pregnant women. This is because pregnant women are more likely to be admitted in hospitals for intensive care as compared with nonpregnant women (Morbidity and Mortality weekly report, Extend Fertility, 2020). Several debates are focused on whether to extend family during the coronavirus lockdown or not (Caron, 2020), the availability of contraceptive pills (NHS, 2020) and increase in domestic violence (Welle, 2020), but none of the literature so far has presented pregnant women’s lived experiences during the lockdown and suspension of medical services.

Marques et al. (2020) emphasized about violence against women during COVID-19. They discuss some factors increasing women’s vulnerabilities to violence during the social distancing and lockdown period and further elaborate that health professionals are essential for screening and responding to violence against women during the pandemic. Ildenir et al. (2021) identified that social isolation impacted the lives of the population in general, in social and economic aspects, with a decrease in the number of complaints of domestic violence against women and an increase in cases of femicide. Moreira and da Costa (2020) studied intimate partner violence (IPV) as a global pandemic and many have been victims of it long before COVID-19. They examine the main risk factors more commonly associated with IPV reflect on how these risk factors may be exacerbated during the COVID-19 pandemic. Sánchez et al. (2020) analyze the existing scientific literature on strategies and recommendations to respond to violence against women during the implementation of social distancing measures in response to the COVID‐19 pandemic.

The above literature studies the impact of COVID-19 on women from violence, aggression, women being victim and vulnerable to violence, etc. but none of the literature has studied the health challenges faced by the Pakhtun women in the Khyber Pakhtunkhwa (KP) province, Pakistan. The present study, therefore, focuses on the experiences of women with health needs during the lockdown. This paper studies how COVID-19 has affected the life of conservative Pakhtun women who already face hardship in getting an education and employment (Naz, 2018). The researcher analyzes three different themes in this paper – social values, cultural values and religious values – to understand how health needs are met in times of limited access to adequate medical services in a traditionally conservative society in KP and how women respond to receiving service from a male gynecologist during an emergency.

Methodology

This explorative study is based on qualitative fieldwork interviews and ethnography. The research took place in three rural and pre-urban settlements in Mardan and Peshawar, KP province, Pakistan. The researcher conducted qualitative fieldwork interviews and participant observation during ethnographic research from April 2020 to August 2020. For maintaining the ethical requirements of this study, i.e. for maintaining their confidentiality, the participants’ names have been changed. During these six months, every weekend was spent in Mardan or Peshawar to record interviews and observe the participants’ attitudes during the COVID-19 lockdown and suspension of services. Because of the fear of the spread of the coronavirus, reaching out to rural and semi-urban regions was quite a challenge. A total of seven one-on-one interviews were conducted with women affected by the suspension of health services during lockdown. These women were either pregnant or had some medical complications. The study observed both men’s and women’s behavior/attitude toward the medical complications they faced during the lockdown phase. A number of informal conversations with the general practitioners were also conducted to understand the doctors’ position during the lockdown phase.

To better understand the Pakhtun cultural and traditional restrictions, emphasis was placed on conducting ethnographic research, which helped in exploring, additionally, how they perceive seeing a male gynecologist in terms of their social, cultural and religious values.

The fieldwork research interview questions were open ended, and the participants were asked the following main research questions with some follow-up questions from discussions (they are listed in the text below):

RQ1.

How has COVID-19 affected you?

RQ2.

How was your personal/lived experience in the lockdown phase?

RQ3.

How has access to health services been challenged due to lockdown?

RQ4.

How do you overcome those challenges?

The fieldwork interviews were not recorded, keeping the cultural practices of the participants in consideration. The researcher preferred their comfort and took fieldwork notes all the time. Their responses and mannerisms were keenly observed and questions were repeated, if required. The interview/discussion environment was kept as friendly as possible. The author had the leverage of earning the trust of the participants for two main reasons:

  1. being fluent in Pashto language; and

  2. coming from the same Pakhtun social and cultural setup.

The selected participants were from both working (teaching profession) and nonworking women. Most of them were housewives living in a joint family system (where a married couple shares the house with extended family members such as their parents-in-law, siblings-in-law and their families and aunties and uncles along with their families. Men’s responses to the interview questions in an informal conversation were also recorded for better analysis. The study found that the Pakhtun men avoid discussing their women's experiences with unknown people. The age of the participants ranged between 22 and 30 years. The total number of pregnant women interviewed was seven. Among these seven participants, three were employed in the teaching profession and four were unemployed. Interviews were conducted during the day time considering their availability and household work environment.

The participants were from the varying economic classes, i.e. from lower to upper-middle class. The researcher spent time with women gathered in their common areas, such as courtyards, busy in cooking, cleaning and holding discussions. The participants trusted the researchers to open discussions/conversations about their experiences during the coronavirus pandemic.

After recording the participants’ experiences, it was crucial to consider the medical doctors’ opinion on the subject. The researcher discussed with doctors to learn from their experiences the number of women trying to visit them outside hospitals during the suspension of medical services. They reported a decrease in patient turnout in outdoor patient departments as well in the indoor patients throughout Pakistan from March 20 to May 12, 2020.

This paper uses thematic analysis to analyze qualitative fieldwork interviews. The study conducted interviews and detailed research to understand women’s lived experiences during the COVID-19 pandemic. The researcher familiarized herself with the problems faced by Pakhtun men and, in particular, women during the COVID-19 lockdown phase. She then prepared codes from the interview transcripts and prepared general themes or categories; reviewed those themes and named them as cultural and social values and religious constraints to see a male gynecologist.

The analysis led to the examination of what expectations are associated with women in the Pakhtun society? What is the role of COVID-19 in it? It helped analyze how they manage to attend to their health concerns and how Covid-19 created opportunities for low-scale medical practitioners. During the COVID-19 phase, where do women stand today in terms of their position in society? Which particular segment of society is affected negatively by COVID-19?

Findings and analysis

COVID-19 lockdown policy changed the life of women across KP. They confronted several challenges including finances, domestic violence, depression, anxiety, loneliness and health. Each one of these challenges affected women’s lives negatively. Keeping women’s suffering in special consideration, this study tried to conduct open-ended interviews and informal discussions with women in a friendly environment where they can feel relaxed and comfortable. For this research, the author interviewed women who went through traumatic abortions during the COVID-19 lockdown phase. The women mentioned that the issue was not only going through a painful pregnancy situation during COVID-19 but having had to visit male health practitioners for their dilation & curettage (D&C). Therefore, the researcher had to remain within the ethical standards of research by paying extra attention with the research questions keeping their physical, emotional and psychological conditions as a priority. The researcher found that the sensitivity of their condition was not just limited to their personal experiences but extends in the form of cultural pressure as well. In the Pakhtun society, seeing a male health practitioner is completely unacceptable for women. Because of this, the family members, especially the husband, had to go through a lot of pain if his wife was treated by a male gynecologist or health practitioner.

During six months’ fieldwork in the rural and peri-urban districts in Mardan and Peshawar, the researcher found that pregnant women from both the affluent class and the lower class were affected negatively by the suspension of services. They were forced to adopt certain measures such as seeing a male gynecologist for their deliveries or medical complications against their cultural, social and traditional constraints. The study also found that in areas where COVID-19 measures restricted doctors from seeing their patients, it also provided a window of opportunity to low-scale unqualified medical practitioners with limited basic training. These inadequately trained health practitioners provided all types of medical services including surgeries, gynecological services and mental health facilities to the general population.

The findings shed light on the impact of educational background, empowerment and religious beliefs on the decision-making process in their lives. The findings also suggest that irrespective of their literacy level, women in Pakhtun society are bound to observe purdah (the seclusion of women from the sight of men or strangers), obey their men and follow their social and cultural practices (traditions). They also consider a patriarchal arrangement in their society according to the teachings of Islam; therefore, they assume that it is their social and religious responsibility to preserve the honor of their husband and male family members. COVID-19, however, has further exposed them to health risks, especially during pregnancy; therefore, this paper attempted to understand the impact of curtailed health services during lockdown on Pakhtun women’s health and well-being.

This study also found that women’s position in the decision-making process in the Pakhtun society appears to be marginalized. An overall lack of education, a limited understanding of their religion (Islam) and the patriarchal nature of the communities may mean that the power structure will revolve around men. Women’s mobility might be restricted, and it may seem insidious from the perspective of Pakistani women who live under a strong patriarchal system, which instills in them a belief that men are superior to women.

Pregnant women experiences: cultural and social values

In April 2020, the researcher learned about a family from a member of domestic/household staff that a young woman named Shahida in the nearby village recently had a miscarriage by a village male health practitioner. Since then, everyone in the village is talking about her. For this study, it was important to explore what were the circumstances that pushed her to get her D&C by a male health practitioner; therefore, the researcher decided to approach her to find out about her general well-being.

On approaching the family, the researcher found that Shahida, a housewife in her early 20s lived in a house with her in-laws. They share the same cultural and social values where speaking to strangers about their issues is considered taboo against the respect/honor of the male member of their family. Therefore, respectful of their values, the researcher had some general discussions in the first meeting with Shahida and deliberately avoided asking about her D&C procedure. While having a conversation with her and her in-laws, the researcher found that she was the second wife of her husband, who was previously her brother-in-law (the brother of her husband) whom she was married to after the death of her first husband. Being a widow and a mother of two young daughters, she had to spend four months and ten days Idat period at her in-laws (a period religiously commanded to be observed by women after the death or divorce of husband, to rule out pregnancy from the previous spouse). After that period when her parents wanted to take her back to their house, her in-laws decided to get her remarried with their youngest son. It was quite a challenge to accept her brother-in-law all of a sudden as her husband and become his second wife, but the tribe and family decided for her future and got her married, despite the first wife of her husband being unhappy with this decision. With a second marriage, Shahida has many fronts to deal with: her own life and her husband’s unhappy first wife. She said that:

I thought my situation might improve if I conceive a child with my second husband. Everyone in the family kept reminding me that I have to compromise with my problems as this is my second ‘chance’ to live life the normal way (being married).

After spending time with the same family and villagers, the researcher found that it was considered a threat to the respect and honor of that family if she was married to someone else. Her marriage outside the family was not only exposing her to extreme honor values but her daughters too. Shahida’s D&C incident became important for this study to find how this family allowed her to do the D&C by a male practitioner.

On the researcher’s next visit, Shahida behaved in a friendly and comfortable manner. During this visit, the researcher was interested in spending one-on-one time to know about her experience during the lockdown phase, especially the incident of D&C. After spending an hour in general discussion, the researcher steered the conversation toward the pandemic and politely asked her in an informal way as to how it has affected her. She shares:

Covid-19 lockdown put a lot of family and financial pressure on me and my family. Pre-lockdown my husband works in Peshawar but, since lockdown, he became jobless and returned home due to the lockdown. I had no issues with him coming home but since jobless, I have to see him making frequent trips to his first wife's room who is already unhappy with my presence in her life. I think she pollutes his mind, maybe that's the reason he often fights with me and at times gets violent. But, when I complain to my mother, sister and mother-in-law they suggest to stay quiet as this is my second chance to stay married therefore I cannot afford to complain.

Researcher:

How do you feel about this?

Shahida:

Not at all! One day I found out that I am pregnant and expecting my first child with him. I was glad that maybe it would bring a fresh breeze of happiness in my life. He seems to be delighted with the news as this was his first-ever child. Our family life improved as he started taking care of me despite our tense financial circumstances. After two months of being pregnant, I developed some complications but by that time Coronavirus already happened and ruined our life. I tried to visit a lady doctor but the lady doctors stopped seeing patients during the lockdown period. My health situation was getting worse with each passing day. My husband and I tried to visit all nearby villages and Mardan city to find a lady doctor who can help with my pregnancy complications. We knocked at the lady doctor’s hospital doors but were refused to be served. My pains were becoming unbearable and life-threatening. My mother-in-law took me to the old lady in our village who helps lady doctors during deliveries. But, she refused to take my D&C as it was complicated. She suggested a male health practitioner in the next village who was not a male gynecologist by profession but had some knowledge. My mother-in-law got offended with the idea altogether. When we got home I discussed it with my husband but he did not even let me complete the story and gave me a shut-up call. But, my condition got worse that night. Ultimately, the only option we had was to seek medical help from the male health practitioner or they let me die. Therefore, we went to him. The health challenge during the lockdown phase has completely changed my outlook on life. I not only lost my child but lost my respect by getting the D&C done by a man! After D&C, I am unable to match eyes with any of my family members particularly my husband and fellow villagers. Who consider I bring shame to their life by seeing a male for the D&C.

Observing purdah is the most significant aspect of women’s life in the Pakhtun society and is associated with their honor. In the case of Shahida, it appears that Shahida tainted the family and society’s honor by receiving an emergency medical treatment from a male health practitioner. Since then, her husband feels embarrassed and feels that people look down upon him and his family.

Samia, a 28-year-old woman, works as a teacher in a well-known private school and comes from an affluent and educational family in Mardan (a major city of KP). She was about to deliver her second child in May 2020. She was a registered patient at the Combined-Military Hospital (CMH), Mardan, a military hospital where civilian patients can also receive medical treatment. Samia’s pregnancy was going well until COVID-19 changed everything for her. When asked how COVID-19 has affected her, she started shedding tears while holding her baby girl close to her heart.

She got all of her regular medical checkups at CMH. But since all medical services were suspended because of the COVID-19 policy implementation, CMH also stopped seeing its registered civil patients. The COVID-19 policy left Samia with confusion as to where she will deliver her child, which was soon due. She visited hospitals with maternity clinics in Mardan and Peshawar, but no medical/emergency service was available. She explained:

The panic I confronted was not good for my health and my baby. She shared that I could not sleep those days. I kept holding my baby in the womb and tears were not leaving my eyes.

Her husband who was educated and financially stable enough to bear the burden of getting their child delivered even at expensive maternity hospitals went through a lot of stress and anxiety by checking on doctors, knocking on their door and considering even local doctors whom they may not consider under normal circumstances. The psychological stress and the pressure of delivering soon kept them on their feet all the time. The couple finally managed to arrange a private lady doctor in Peshawar and reached her during the final labor pain period. She was thankful for the support and help she received from her husband. When we asked the husband if he would have considered a male gynecologist when Samia was going through labor pain, he went quiet and ignored answering this question.

Nenai, a 25-year-old woman, was expecting her twins in a peri-urban village near Nowshera region. She was expecting her first babies after marriage. She is educated with a graduate degree but prefers to be a housewife like many other girls of her family. When she was asked to share her experience about how COVID-19 has affected her, she opened up with another extreme story. Nenai shared:

My life turned dark when my lady doctor refused to see me further due to the suspension of services. She was in her third trimester. Being pregnant with twins was itself a challenge for me. My husband who is overseas also went through a lot of stress and anxiety. My in-laws knocked on the gynecologists’ doors but no help was available. We tried seeking help from our extended family to get us some medical help but we failed. With depression and anxiety, I build up with pregnancy complications. My in-laws had to take me to the emergency but the emergency also refused to see me. We waited, begged but our efforts went in vain. Finally, I got unconscious with extreme pain. My in-laws ended up with a lady doctor in the nearby village for operating my twins whom we will never visit under normal circumstances. When I regained consciousness another tragic news was waiting for me that I not only lost my baby girl but a boy was delivered prematurely. Now the challenge was to deal with a dead child and a premature baby who needed an incubator. But, as the lady doctor was not having proper medical arrangement we were asked to leave and take the baby home. At that time, I struggled to understand how to deal with losing a child and securing a premature child who needed intensive medical care. Being in a mental shock I could not deal with the situation well as my husband was not with me and I was not in a position to handle this unfavorable environment.

Nenai, with sadness in her sad voice and eyes, shared:

I am extremely thankful to Allah for securing my baby boy whose life was a miracle to happen in that unforeseen situation.

Her parents and in-laws fully supported her throughout, but her pain was severe and she is still going through the pain of losing her baby girl. The researcher was extremely touched with the lived experiences of Shahida, Samia and Nenai. The researcher wanted to explore further why this society considers seeing a male health practitioner against their social and cultural values. Therefore, it became essential for this study to get some perspective on the subject by adding some follow-up questions.

Religious constraints

During the ethnographic research study, the researcher spent time with families in the rural and peri-urban setup near Mardan and Peshawar. After spending time with these families, the researcher found that most of the women were housewives with little interest in getting an education and seeking empowerment compared with the women in the peri-urban districts who were keen to get employment. But in terms of friendliness, affection and care, women in the rural areas were as warm as the peri-urban district women. The researcher found that women in the peri-urban districts were more occupied and unable to give time to participate in this research, perhaps owing to the demanding nature of their household and office work. The women in the rural regions stay at home all day long, do their household chores and take care of their farms and animals, while the men either work as laborers in the Middle East and the Gulf states or work in the cities in low-scale jobs or work on their farms.

The researcher tried to record the women’s attitudes toward seeing a male gynecologist deliver their child and found that none of them support the idea; however, they shared that their lady doctors do refer them to pay visits to a male sonographer located in Mardan. In certain situations, they accept to have their pelvic ultrasound done by a male sonographer; however, they observe strict purdah, which is hard to maintain during the scan. They shared that there is only one colored scan sonographer available in their locality; therefore, they have no choice.

The researcher asked the participants that if a male sonographer in times of need is acceptable, then how about seeing a male gynecologist in times of emergency?

Beena, a young woman in her early 20s, said that:

It is unacceptable in the religion to show your private parts to any men but their husbands.

Researcher:

How did you learn about these restrictions?

Beena:

This is how it is from ages. We (women) are religiously not allowed to go against religious beliefs and restrictions. We have to maintain the respect and honor of our men because this is what religion tells us.

Although she could not support her belief by tracing it back to religious injunctions, her position appeared unwavering.

Sidra, a young woman in her late 20s, shared:

It is against her own Pakhtunwali culture. She further stressed that by visiting a male doctor especially for deliveries we will bring shame and disrespect to our families. She further emphasized that being a Pakhtun woman this is my responsibility to preserve the respect and dignity of my family.

Being raised in this society, women are trained by their elders that they are not expected to ruin their family respect, which is associated with the male honor. Getting men’s perspective on the subject was equally important to this study. The researcher found that men in the Pakhtun society are respectful toward women. They keep their gaze low while addressing a stranger, especially a woman. The researcher reached out to Dilawar with the help of his wife who worked at a marble factory. The researcher asked Dilawar about his experience during the lockdown phase. He shared:

Covid-19 tested both my financial capabilities and personal life. I was jobless and at the same time had to supply all the necessary food staples for the survival of my family. Being the only breadwinner I went through a lot of pain and hardship. Secondly, my personal life was also at a halt. There was no free medical service available. My family became victims of Coronavirus but we never went to get medical help from the government. The fear of quarantine maltreatment kept me and my family at home during the entire Coronavirus illness. Also, it is against our social values to send your women to the quarantine centers or you (men) go to the quarantine centers and leave your women behind.

Indeed, the coronavirus and the policies to manage COVID-19 have affected the lives of both men and women, who have had to go through emotional, social, psychological, financial and medical (health) pressures. It has tested the social fabric of societies and left it with unrecoverable scars of fear and concerns among those affected by the medical services suspension.

Doctors’ experiences

Dr X, a Cardio surgeon at a private hospital, was asked about his experience during the suspension of services. He shared:

During the suspension of services, I stayed at home and was on call. We were not allowed to see patients privately due to the fear of Coronavirus. Also, we deal with highly sensitive heart patients who are already vulnerable to infections and viruses after heart surgery. We do have a gynae department working in our hospital. I always wondered where these pregnant women will go as doctors were not allowed to treat them in the hospitals. The issue was not only pregnant women but all men and women with cardio, cancer and all other diseases who were registered in the hospitals but suddenly were refused to be treated further. Being on call I tried to extend my services via phone but that was insufficient for my cardiac patients who required urgent surgeries. Another issue was the insufficient number of available ventilators in our hospital. For every heart patient after surgery, a ventilator is required to monitor his/her heart but since Covid-19 all ventilators were reserved for Covid-19 patients. That was not a solution to the required hospital needs of normal versus Covid-19 patients. Even now the issue is not only handling the cardiac patients with their existing health condition but their exposure to the deadly Coronavirus.

In the current hospital setup, patients have to bring their COVID-19-negative report to be treated in the hospitals. The doctors not only had to protect themselves and follow the SOPs but also save patients with severe health conditions.

Dr Y serves as a senior nephrologist specialist in Peshawar. His three sons are general practitioners, while his wife is a gynecologist. When this family was approached and asked how the COVID-19 lockdown and suspension of services has affected them, they shared:

Due to the fear of Covid-19 we were pushed to stay at home and remain on call. We were concerned about our patients but there is nothing much we can do. We cannot risk our patient lives by exposing them to the deadly virus. At the same time, this is our responsibility to abide by the Covid-19 policies set by the Government of Pakistan. We cannot deviate from the rules in such an emergency.

The wife (gynecologist) was asked if she was treating women on the phone or considered seeing her regular patients at home. She said:

I do offer my services over the phone but in cases where deliveries were concerned, I was unable to take risks. For that, I need to be exposed to the patient and so is the patient's exposure to me. I am afraid that if the patient carries the Virus already or the patient may get exposed to the Virus during the entire process of delivery. This is like a threatening situation for all three of us: Doctor, mother, child. I do hold my concerns that where will they go to seek medical help if I refuse to see/treat but I cannot deviate from the rules set by the government during this unforeseen situation.

This shows that the fear or concern for getting infected was higher, which both doctors and other participants share. So besides the government’s COVID-19 policy, it’s the caution and concern that made it not possible to access health services.

Dr Z, a local gynecologist in the rural area near Mardan, shared that:

Since Covid-19 there has been an increase in the number of patients. Every week I conduct three-four deliveries. Allah has been very kind and supportive during this tense environment. I wear a mask and apply sanitizer before seeing any patient. That’s all that we can do. These patients need me and I need them.

The strict lockdown policy and suspension of services created an environment where hospitals curtailed their services for the general public, but smaller private clinics in the rural areas took it as an opportunity to treat more patients than usual. As a matter of fact, irrespective of the financial status, the suspension of medical services was for all and felt by all segments of the society.

Psychological impact of the lockdown on women’s health

There is a consensus among mental health professionals that women were more vulnerable to be exposed to psychological and physical health challenges during the pandemic. For both stay-at-home mothers and working women, the demands multiplied due to the prevalent norms of community and society. In a culture where women are considered to be primarily responsible for the care and household duties, the burden increased as the family stayed home due to lockdown. Especially in communities with patriarchal values, the distress takes a greater toll on women’s physical and mental health (Khan et al., 2009). It is concerning to note that during lockdown around 243 million women have possibly experienced sexual or physical abuse at the hands of an intimate partner (Lancet, 2020).

The lockdown also resulted in limited medical access for many urgent health concerns. This especially had a detrimental effect on women’s health where the prevalent norms determine when and where to access health service. Marie Stopes International (MSI), operational in 37 countries, estimated that up to 9.5 million vulnerable women and girls would lose access to contraception and safe abortion services in 2020. This may lead to health and life risks for women because of unsafe abortions and pregnancy-related deaths. MSI reports that because of mobility restrictions during countrywide lockdowns in low-middle-income countries such as Nepal and India, neither providers nor clients could reach clinics, thus causing distress among women who required services for abortions or contraception.

The lack of access to health facilities for pregnant women becomes critical if the cultural norms put restrictions on women and families to choose services only from women health professionals or paramedical staff. The stories narrated to the researcher during this study revealed the silent trauma a woman has to go through if she is denied access to health care because the provider is a male; therefore, it would be a stain on the honor of her husband if she is seen by a male doctor for pregnancy-related issues. Particularly in a situation where one participant had to be treated for a miscarriage by a male health worker, she was able to save her life but still carries the shame of tainting her honor and that of her family. Culturally in the collectivistic tradition in Pakistan, a woman is both respected and ostracized because of the association of the family’s honor with her. A woman who submits to the norms and wishes of her husband and elders is respected for her subjugation, whereas if she somehow becomes the person who violates the norm, the stigma stays with her and she receives unfavorable treatment from the family as well. The woman in such situations went through both psychological trauma and feelings of shame and guilt, which may have a long-term impact on her well-being. It is, therefore, important that during times of public health crisis, the health advisory and preventive measures, in this case the lockdown, should also take into consideration how these measures would exacerbate the health condition of vulnerable individuals in a particular cultural context. It is also important to provide culturally relevant and acceptable alternate health facilities for women and children to avoid the unintended psychological consequences of preventive measures during a pandemic.

Conclusion

The Pakhtuns can go to any extent to defend their women and believe that Pakhtuns should always be ready to protect their honor and stand bravely against tyranny; if they are not brave enough to protect their land and women, they should not claim to be Pakhtun. This paper aimed to study the Pakhtun pregnant women who confronted complications in their pregnancies and and failed to avail the health services as hospitals were restricted to cater to the needs of the emerging health crisis in the COVID-19 lockdown phase. It is evident from the above discussion and analysis that the Pakhtun society is characterized by a strict and conservative attitude toward their women. They consider their women as their respect and honor; hence, they can go to any extent to protect their respect and honor. Their women are bound to observe purdah seclusion, i.e. physical segregation of the sexes and covering their bodies. They have to avoid male health practitioners even if they are under potentially fatal health conditions. This society abides by their tribal culture, traditions and norms. With the suspension of medical services because of the COVID-19 pandemic, the Pakhtun women are confronted with two major challenges:

  1. how to maintain their health; and

  2. to sustain their social and cultural norms.

In this society, women are expected to obey men under all circumstances. COVID-19 further worsened women’s position in the society with reference to their health. Indeed, COVID-19 created opportunities for low-scale medical practitioners in both urban and peri-urban districts because of the suspension of medical services but women, during the suspension period, had to face psychological, emotional, physical, and social well-being challenges. It will be difficult to ascertain a particular social segment from which the women were worst affected during the suspension period; the research shows that both the affluent and the lower-class women were affected negatively because of the health crisis.

COVID-19 is differentially impacting individuals in societies, with inequality in systems and policies (FAO, 2020). As reports of suffering because of the closure of public health services are commonly seen, it is about time we learn from our experiences and act, plan and design policies considering all segments of the society.

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Acknowledgements

The author is extremely grateful to Professor Salma Siddiqui, who read the entire manuscript and made very useful comments on the initial draft of this paper, which certainly improved the quality of the paper. The author is highly indebted to her. However, any errors or omissions are the sole responsibility of the author.

Corresponding author

Farah Naz can be contacted at: farahnaz@s3h.nust.edu.pk

About the author

Dr Farah Naz is Assistant Professor at the Department of Government and Public Policy, National University of Sciences and Technology. She is also one of the trainers at the UN Peacekeeping Training Department. She is recognized for her work on extremism and radicalization leading to terrorism, especially in the digital age. She has a decade-long experience in academic and policy settings of leading research and providing policy input on the subject. She has advised the Government of Pakistan and the Government of Australia on the subject. She has published and presented extensively in numerous journals, policy outlets and international conferences. She has a PhD from the University of Sydney and an MPhil from National Defence University. For her work on countering violent extremism in the digital age, she is recognized and has received Distinguished Endeavour Leadership Award from the Australian Government Department of Education, Skills and Employment.

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