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Effects of mother-daughter communication on reproductive health in Pakistani society.

The relationship between a mother and her child is one of the most beautiful relations on this earth; it gets more beautiful when it is between a mother and a daughter (Hamdani, 2012). It is a commonly held view that girls usually are a reflection of their mothers. They behave like them; they have similar likes and dislikes. Siler (2007) rightfully observes that most of us find it hard to understand the extent to which the mother-daughter relationship influences a woman in shaping her behaviour, communication style, and the choices she makes in her life. Whereas most of this nonverbal behaviour is learnt unintentionally from mothers, this paper's concern is to explore the nature and effects of verbal communication between mothers and daughters in Pakistani society.

In Pakistan, most mothers are not very candid and frank with their daughters and some topics are taboo for discussion. Issues related to women's bodies, such as menarche, on-set of menses, sex life, and reproduction are such topics and carry age-old prohibition labelled as shame-causing issues. The present study, therefore, aims to discover if this non-communication on mothers' part has any significant effect on daughters' reproductive health, before and after marriage.

Although the World Health Organization's (WHO) definition of health as a state of complete physical, mental, and social well-being, and not merely as the absence of disease or infirmity (Grad, 2002) predates Pakistan's creation, Pakistani society, burdened by traditions, has yet to accept it. The traditional and custom-bound notions of health play a negative role in maintaining the quality of women's health, particularly their reproductive health. Reproductive health, as against the commonly held traditional view, is not about pregnancy and birthing only; it encompasses the whole life span of a woman's existence. It addresses the total reproductive processes, including all functions and system at all stages of life. Reproductive health, therefore, means that people are able to have a reliable, satisfying and safe sex life and also that they have the capacity to reproduce and autonomy to decide if, when and how often to do so (WHO, 2012).

In countries like Pakistan, the communication between mothers and daughters on the issue of reproductive health, as said above, is still restricted. Recent studies indicate that higher education of the mother, as well as more awareness of reproductive health issues, love, and mutual understanding between partners, promotes better communication between mothers and daughters. On the contrary, shyness, poverty, lack of access to mass media, misunderstanding between spouses and misinformation about reproductive health, inhibit this communication (Khan, 2000). A question that often comes up, in societies such as Pakistan, is why should parents discuss these matters with their children? This paper looks at factors that hinder this process of discussion and act as barriers in communication and flow of information.

Family plays an important and influential role in sexual socialization of children and youngsters. The information and messages that are (or are not) communicated between parents and children have the potential to outline sexual decision-making all through adolescence (Diiorio, Pluhar & Belcher, 2003). In fact, puberty, which is an important indicator of adolescence, is a time marked by biological, emotional, social, and psychological changes (Steinberg, 2006). As several changes that are difficult to handle for the adolescents, occur at this time, adolescents need someone with whom they could talk about these changes without hesitation and they need guidance from a source they could trust blindly. Thus, parents' role is very important at this time. Moreover, this age leads to reproductive years later. Reproductive health or reproduction is one thing, which provides the basis for the continuity of the human race. Reproductive health, being a vital part of general health and a central characteristic of human development, is a manifestation of health during childhood as a healthy childhood leads to healthy adulthood. Moreover, reproductive health is critical during adolescence and adulthood because in these years, secondary sex characteristics began to grow. In addition, hormonal secretion sets the stage for further reproductive years for both women and men. More importantly, it affects the health of the next generation in a very significant way (Kotwal, Gupta & Gupta, 2008; Kunnibe, Nkegbe & Abdul Mumin, 2012). Proper information and guidance, therefore, at this crucial phase of life is of extreme importance. Research suggests that a majority of adolescents age fifteen and above have an extreme wish to get proper information on sexuality, which includes knowledge about the physiology of puberty, aspects of sexual behaviour, sexually transmitted diseases and marriage and childbirth (Omran & Al Hafeez, 2006). A study conducted by Ayra (2009) highlights the importance of mothers' communication with their daughters. She suggests that a mother should keep an open communication on all matters with her daughter and answer all questions that come to the young female's mind.

In this context, we see an opposite role of Pakistani mothers. As the number of dual career couples is increasing, parents overall have less quality time for their children, thus neglecting and overlooking proper and timely sexual education for their girls and boys, which is much needed at this time (Omran & Al Hafeez, 2006). Thus, open discussion of sexuality is not encouraged in Pakistan (Khan, 2000). This is not particular to Pakistan only; it is the case with the rest of the South Asian countries. If any information is provided, it is poor in quality and often myth-based (Khan, 2000). Compared to girls, boys acquire better awareness not only about their own sexuality but also about the opposite sex (Hennink, Rana& Iqbal, 2004). A commonly held notion that this ignorance acts as a weapon against premarital sex is another myth that fortifies the phenomenon of unawareness about reproductive behaviour (Mensch et al, 1998). Ironically, even married girls in developing countries have little knowledge about reproductive health and about how to protect themselves from sexually transmitted diseases. The information, which adolescent girls usually receive, on the sexual and reproductive issue from female members of the family, is at the most about menstruation while information on sex is passed to the girls only on their wedding day by some newly married female relative (Mumtaz & Rauf, 1996). This lack of knowledge is also verified by George (2012), who worked with Indian rural girls, where most were unaware about menstruation and considered their first bleeding as a symptom of cancer or a result of some injury. Similarly, Chung, Straatman, Cordova, Reynaga, Burchfield & Kavanaugh (2001) in a cross-cultural study revealed that across cultures, women frequently talk about the physical and psychological implications of their menstrual cycles. These 'womanly talks' are marked, however, by phrases and words peculiar to 'women's language'. These peculiar linguistic nuances indeed show what Chung et al (2001, 4) in their study Menarche and its Implications for Educational Policy in Peru aptly describe as 'a universal reluctance to discuss the process directly.' In Pakistan, similarly, 'respected' and 'good' women and girls, across all geographic spaces, are not supposed to breach the code of honour by talking about 'shameful' things. Thus, as a woman's body must remain covered per the country's honour code, similarly all things connected with this 'body' must remain cloaked.

Recent studies have verified the fact that proper information about her body and its functions is necessary for a girl to act as a responsible human being. This knowledge not only generates a sense of security and prepares her to face the upcoming challenges of reproductive life, but it marks the first step in the direction of self-empowerment. Mothers can act as safe and trusted conduits for the transference of this information. This role, however, does not happen. Mothers not only hold back this information but discourage their daughters from talking about these matters, create fear, apprehensions, and myths about 'facts of life'. Now the question arises as to what are the factors that promote or inhibit mother-daughter communication and generate 'silence'.

Rastogi and Wampler (1999) in a cross-cultural study found that ethnicity plays a more important role in closeness and a trust-based mother-daughter relationship than do income and education. Fox and Inazu (1980) found that white mothers are comfortable talking with their daughters about menstruation and dating but are less comfortable about sexual intercourse whereas daughters felt much less comfortable discussing these topics with their mothers. Similarly, Hutchinson and Cooney (1998) concluded that discomfort among parents and teens is an important reason for low rates of communication among parents and teens.

Koblinsky and Atkinson (1982) found that most parents belonging to the middle class intended to take part in their children's sex education. On the other hand, research conducted by Smith and Self (1980) indicated attitudes of mothers as a significant predictor of daughters' attitudes. They suggested that attitudes of mothers affect the development of sex roles among daughters.

The above findings highlight the importance of education and economic status in mother- daughter communication. Keeping in view these findings, this research study was designed to explore the existing mother-daughter communication scenario in Pakistani culture. Does education play a role in making the situation better? What are the problems that daughters face because of less communication on their mothers' part? It was hypothesized that educated mothers would have more loving relations with their daughters. It was also hypothesized that uneducated Pakistani women would not be very friendly with their daughters and that overall, Pakistani women would not be equipped with proper guidance about reproductive matters, and especially that mothers would not be the source of guidance. Education would play an important role in open communication between mothers and daughters, and open communication would lead to better reproductive health for daughters after marriage.

In addition, it was supposed that overall, Pakistani women would be hesitant to discuss the reproductive health issues with their daughters. Less information and guidance about reproductive health issues would cause problems in daughters' life after marriage. The kind of relationship between mothers and daughters would play a role in making their communication better. Results lent support to some of these hypotheses.

Study Methods

This study employed quantitative research methods to obtain information about mother-daughter communication regarding reproductive health. This research was conducted for the completion of the MA degree and it was not funded by any agency. Participants in this research were daughters who were asked about their relationships with their mothers. They were also asked about the nature and extent of information which their mothers had provided them about reproductive health.

An indigenous arbitrary questionnaire was used to collect data from educated women; the same questionnaire was used as an interview schedule for uneducated women. The questionnaire was available in both Urdu and English languages. There were twenty-five questions in the questionnaire. A pilot study was conducted to evaluate the questionnaire for language, grammar or any other ambiguity. No question was discarded because of the pilot study, but language and grammatical issues were dealt with after pilot study. Once finalised, it was used in conducting the actual study.

Participant profile:

The sample of the study consisted of seventy married women who were further segregated based on education (ranging from non-educated to Masters Level) with an age range of twenty-one to sixty years. The economic status of the participants was also considered. Moreover, the quality of the relationship between mothers and daughters was also taken into account. Snowball sampling was used to collect data. Educated women were of varying backgrounds, from housewives to lecturers, doctors and office workers; uneducated women were housewives, maids, home workers and women working in factories. The entire sample was Lahore based, but participants represent different geographical locations of Pakistan. Not all were natives of Lahore; some have come from different cities in Pakistan.

Procedure of Data Collection

First, the informed consent of the respondents was taken. Initially, the uneducated women showed resistance, were quite reluctant, and hesitated in providing information. The participants were explained the purpose of this research and were assured that the information taken from them would be kept confidential and would be used for research purposes only. Once convinced of anonymity and confidentiality, resistance melted and the data was collected from all seventy participants. Working women, either educated or uneducated, were contacted at their workplaces whereas housewives were contacted at their homes. For uneducated women, a questionnaire was used as the mode of interview. The researcher conducted these interviews, which lasted thirty to forty minutes. Prior to the interview, she went through all the steps necessary for conducting interviews, such as rapport building, active listening, use of nonverbal cues, and how to facilitate the discussion.

Analysis

The collected data was subjected to further analysis. Frequencies and percentages were calculated and graphs were made to elaborate the results.

Results

The results indicate firstly the demographics of the participants. See table 1. The results indicate the level of interaction between mothers and daughters. 85.71 percent of educated women reported friendly terms with their mothers. The case of uneducated women was also the same, but their percentage was less than that of educated women i.e. 65. 71. A smaller number of respondents defined their relations as reserved. Here again, more uneducated women (25.71) declared relations with their mothers as reserved. On the other hand, for educated women this percentage remained 14.28%. Only a few women (8.75%) from the uneducated background wanted to be friendly with their mothers, but the mothers never allowed them to do so. No respondent reported that their mothers wanted to be friendly with them, but they (daughters) did not allow it. As all the participants of this study were married, hence we refer them as women. See figure 1 for graphical presentation of data.

The participants were further asked whether they received guidance from their mothers about reproductive health issues. The results indicate that a vast majority of participants did not get any information from their mothers about reproductive health issues (82.85% from educated group and 85.71% from uneducated group). The graph indicates a slightly higher-level positive approach in mother's behaviour in educated group. See figure 2 for graphical representation of data.

Next, the participants were asked whether little information created any problem in their married life. Results indicate that 37.14 percent of educated women thought that there were problems in their married life (discussed in next paragraph) because of little guidance, whereas 62.85 percent women answered in the negative. On the other hand, 65.71% of uneducated women considered little guidance as the root cause of their marital problems, whereas 34.28% thought that little guidance created no problem for them. See figure 3 for graphical representation of data.

The next logical question after this was what sort of problems they faced because of their unawareness. The results of this question verified the previous question's results. Most of the educated (85.71) women responded that they did not face any problems and the few who faced problems claimed that these were delivery-related (8.57%) and also included adjustment problems (5.71%). On the other hand, for uneducated women, adjustment problems was the main concern (37.14%), followed by problems they faced during delivery and pregnancy (22.85%) and problems about sexual relations (8.57%) respectively. See figure 4 for graphical representation of data concerning this question.

The participants were asked whether they thought that better information could help in avoiding this problem. Sixty percent of educated women were of the view that it could not; whereas 40% were of the view that it could be. However, 55.71% uneducated women thought better information could improve the situation for them. See figure 5 for graphical representation of data.

Then the participants were asked if a mother's education could play a role in effective communication. While the majority of educated and uneducated women considered it an important factor (91.42% and 88.57%), only a few differed and considered mothers' education as an unimportant factor. Uneducated women outclass educated women in this perception of importance (11.42% and 8.57%). See figure 6 for graphical representation of data.

The next question dealt with the effect of poor communication on daughters. They were to choose from "Little connectivity, dependence on sources other than mother, wrong information can lead to faulty practices and all of the above". A majority of educated and uneducated women were of the view that poor communication creates all the above-mentioned problems (45.71% and 48.57%). For educated women the second highest effect of poor communication was dependence on sources other than mother (22.85%), and for uneducated women the second highest effect was that wrong information can lead to faulty practices (17.14%). See figure 7 for graphical representation of data.

The participants were asked if they would feel more secure if their mother had communicated effectively with them or they had sought the necessary information themselves. Most of the educated and uneducated women responded affirmatively that it would have provided them with a feeling of security (educated 88.57% and uneducated 82.85%). See figure 8 for graphical representation of data.

Finally, the participants were asked what would be their strategy for guiding their own daughters. Of educated women, 68.57% said that they would talk about some, if not all, aspects (which they would find appropriate in a given situation) of reproductive health with their daughters, whereas 25.71% said that they would discuss all the aspects with their daughters. On the contrary, 45.71% of the uneducated women said that they will not tell anything to their daughters and 28.57% said that they would tell some aspects. 25.71% intended to give all information to their daughters. See figure 9 for graphical representation of data.

Discussion

Research has highlighted the importance of communication between parents and children in shaping children's attitudes towards reproductive health (Siler, 2007). However, there seems to be a gap in parent- child communication, not just in our country but also throughout almost all the Asian countries (Chung, Straatman, Cordova, Reynaga, Burchfield & Kavanaugh (2001). Where there is communication, it is mainly on the same sex basis (usually mother-daughter and infrequently opposite sex such as father-daughter) as described by Wamoyi, Fenwick, Urassa, Zaba and Stones (2010). Research also indicates that mother's communication with daughters on reproductive health issues can help the girls in many ways before and after e marriage (Fox & Inazu, 1980). This research study was designed to explore the existing mother-daughter communication scenario in Pakistani culture and to understand whether education plays a role in making the situation better. The study also aimed at investigating the problems that daughter face because of less communication on the mothers' part.

It was hypothesized that educated mothers would have more loving relation with their daughters. Overall, Pakistani women would be hesitant to discuss the reproductive health issues with their daughters. Less information and guidance about reproductive health issues would cause problems in daughters' life after marriage. Educated mothers would have better communication with their daughters. The kind of relationship between mothers and daughters would play a role in making their communication better. Results lent support to some of these suppositions.

Our findings show that mothers of both educated and uneducated women had a loving relation with their mothers. This ratio, however, prevailed more with educated women than with uneducated ones. In addition, more frictional relations appeared in women of uneducated backgrounds; some of them declared their relations with their mothers as reserved. Some respondents admitted that they wanted to be friendly with their mothers, but the latter did not allow that. Non-acceptance of daughters with an open heart is a typical stereotypical mother-daughter relation prevailing in uneducated families. In such families, mothers want to maintain a distance from them because they think that there should not be a friendly relation between mother and daughter.

Our second hypothesis was also substantiated by our findings. Pakistani women do not appear to be equipped with proper guidance about reproductive health matters. Among educated women, 82.85%, and among uneducated women, 85.71% from our sample stated that they did not receive any guidance about reproductive health matters before marriage. It is also in line with previous research studies (Hennink, Rana & Iqbal, 2010) showing that Pakistani women are not informed about these matters before marriage. In a way both the above results are contradictory results because research indicates that if parents are having friendly relations with children and there is a sense of family connectedness, then there would be open discussion (Jones, Sing & Purcell, 2005; Markham, Tortolero, Escobar-Chaves, Parcel, Harist, & Addy, 2003). Our findings do not show this result. Participants reported loving relations, but they did not have any open communication. There can be two reason for this disparity. First, it is possible that girls exaggerated their relations with their mothers out of social facilitation (a more in-depth discussion regarding quality of relations could solve this problem) and secondly, this finding mainly comes from foreign research which could be culturally biased.

Our results also indicate the problems women face after marriage because of lack of awareness. Interestingly, here educated women as compared to uneducated women denied that the problems they faced were because of their unawareness In fact, here the difference is because of the upbringing of the uneducated women. They have access to the internet, books, and other sources of information. Moreover, they can discuss matters with their friends. Uneducated women, on the other hand, have less exposure and access to this information. Their mobility is also restricted and they have less opportunity to intermingle with friends. These could be reasons why they are less aware than educated women; because of their narrow approach, they may feel that they face more problems after marriage. In line with this point, 55% of uneducated women feel that better information could help them to better adapt to married life, whereas just 40% of educated women thought that this information could be helpful to them in overcoming conflicts after marriage.

As far as the question of mothers' education was concerned, the majority of educated and uneducated women felt that mothers' education could play an important role in creating open communication. They also think that poor communication creates little connectivity between mothers and daughters, and it can compel daughters to get information from other sources, which could be harmful to them as described by Child, Youth, and Women's Health Service (2003). Thus, it is very important that parents provide sex education to their children. Teenagers often get erroneous information about sex from their peers. In line with previous research (Hennink, Rana & Iqbal, 2004) which highlights adolescents' need to get proper guidance and information about these matters, studies indicate that 75 percent of teens wish for more information about sexual affairs. They also like to have these types of discussions with their parents (Rodgers, 1999).

This point was also verified by answers to another question in which a majority of educated women intended to guide and inform their own daughters with timely information about reproductive health, but a smaller number of uneducated women intended to do so. This result could also be in line with previous research which states that parents themselves believe that they have a significant role where sex education for their children is concerned (Alexander, 1984). However, most parents find the task intimidating, and they feel that they are ill equipped to perform this task (Warren, 1995; Rosenthal & Collis, 1997; Rosenthal et al., 1997).

Conclusion

Based on the above findings, it can be said that girls should be provided with necessary education and information about reproductive health issues in proper time. Education of the mother plays an important role in this regard. Mothers' education and communication can save the girls from many after-marriage problems. Moreover, open communication can enhance the quality of mother-daughter relationships. As this research indicates, positive relationships between parents and teens create mutual understanding, emotional proximity, and family connectedness. Such proximity allows supportive communication, which specifically links to an improved probability that adolescent females will have discussions with their mothers about sexual affairs (Rodgers, 1999).

Limitations and Future Implications

This research was conducted with daughters only. Information provided by the participants was not authenticated by any other mean. Future research can be done, including the mothers of the same sample, which will help counter check the information. Moreover, another comparison can be made by inquiring about the educational level of the mothers, which would further validate our results. This research could be beneficial for mothers, psychologists, and teachers who are dealing with adolescent girls. It is intended to share this information with concerned persons, such as educators and clinicians in order to obtain optimal and practical benefits from this research.

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Shehla A. Yasin, Sarah Shahed & Tazeen Iqbal

Lahore College for Women University, Lahore

Sarah Shahed, PhD in Health Psychology (the University of Surrey) is the Director of Women Institute of Leadership & Learning and Head of the Department, Gender & Development Studies at Lahore College for Women University.

Shehla A. Yasin, lecturer in the Department of Gender & Development Studies, Lahore College for Women University.

Tazeen Iqbal did her Masters from Lahore College for Women University in Gender Studies and assisted in data collection and data entry.
Table 1: Demographic information of Participants

             Frequency   Age         Education Level   Income

Educated        35       Majority    Bachelors and     5000-10,000
Women                    21-25 yrs   above

Uneducated      35       Majority    No Schooling /    20,000 and
Women                    31-40 yrs   Few early years   above
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Author:Yasin, Shehla A.; Shahed, Sarah; Iqbal, Tazeen
Publication:Pakistan Journal of Women's Studies: Alam-e-Niswan
Geographic Code:9PAKI
Date:Dec 1, 2013
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