Surgical contraceptive procedures are one of the most opted methods of contraception in Pakistan, second only to traditional family planning methods. Despite being such a common practice, there’s a significant gap in medical ethics, particularly pertaining to female bodily autonomy and informed consent prior to a procedure within the local healthcare system. Majority accounts are marred with harrowing stories of women being denied access to such services by the surgeons themselves, being forced into not opting for it by their husbands etc.
“She [the female patient] was nearing her mid-50s, a mother to seven children already from a very impoverished stratum of the society— she desperately begged for a surgical contraceptive as her husband, who was himself in his early 70s, insisted for the seventh child. She couldn’t afford to be a breadwinner to seven children in an instance of her husband passing away. She clearly didn’t even have the mental or physical capacity to carry another womb. Alas! No single hospital or practitioner was remotely willing to provide her a public service.”, a birthworker narrated during my research.
She desperately begged for a surgical contraceptive as her husband, who was himself in his early 70s, insisted for the seventh child.
What was the causal factor behind this healthcare access disparity? If surgical sterilisation had been such a popular option, then what was behind this strange yet deeply impactful accessibility in play? Was it just the patriarchal, cultural norms where the woman’s choice was subjugated by her husband’s or did some part of the blame for this reproductive injustice rest on the shoulders of the healthcare system as well? These questions founded the basis of my investigation as I undertook a deep dive into investigating the dynamics of surgical contraceptive procedures in Pakistan.
Through my comparative research, by conducting interviews of a sample of OBGYN surgeon-physicians along with a pool of healthcare policy specialists— I concluded that while both these factors played a critical role, a murky medical policy guideline was, in fact, augmented with the normative patriarchal oppression prevalent in the society. Commenting on the former element of policy status, a gynaecologist and policy analyst commented on this aspect, “There are a multitude of underlying symptoms to this condition; you have a religio-cultural element vying to integrate itself into the delivery of a public resource. At the same time, more importantly, concepts that are deemed “universal” are also not universal if we look closely.”
This is to affirm that a borrowed medical ethics guideline from the Global North, left de-contextualised, has prompted the creation of a healthcare system that doesn’t cater to the nuanced pressures present in the cultural realm. And there are a vast variety of those— from parental agreement to husband’s consent to perceptive subjugation— all these oppressive forces emerging from the cultural norms have been further enabled by the presence of a deficient policy guideline. Adding on to that, a weak policy regulation system further complicates the issue.
This is to affirm that a borrowed medical ethics guideline from the Global North, left de-contextualised, has prompted the creation of a healthcare system that doesn’t cater to the nuanced pressures present in the cultural realm.
Existing literature suggests that decisions surrounding conception and family planning in Pakistan are significantly determined and influenced by people other than the pregnant women herself1. Often out of familial pressures, women aren’t able to even make it to a hospital or a clinic in the first place. Then there were also those doctors who relied on personally curated values and judgments to decide whether to allow surgical contraceptive procedures or not. These biased judgments, devoid of consistent policy grounding and heavily influenced by normative judgments, have frequently led to exacerbating the challenges surrounding the status of bodily autonomy and consent in parts of Pakistan.
Complete bodily autonomy, especially in the context of public service provision, is a right of every citizen of this country. The undertaken research presents a thorough depiction of the existing healthcare system, particularly within Punjab, as it serves to hinder the aspiration towards attainment of the fundamental ethical ideal of female bodily autonomy. Currently, even in emergency cases, women’s autonomy is threatened and left unprotected at the whims of either the physicians or the family.
To ensure equity in public systems, it is necessary to engage with the complexities of a multifaceted problem and deal with it in a methodical fashion, rather than ad hoc prescriptions.
A good place to start will be by fundamentally revamping the bioethics gynaecological policy guideline and streamline its enforcement across both public and private sector healthcare providers. Along with this, a consistent provision of professional training must also be undertaken in order to equip relevant physicians to deal with both normative and exceptional pressure situations to make informed and value-driven decisions. At the same time, policies must be more concise and allencompassing in their scope to achieve reproductive justice and physical autonomy.
Zain Ul Abidin Khan Alizai is a political science senior at LUMS, where he’s also working as a Research Assistant at LUMS Learning Institute.