It is April 2017. A couple is waiting anxiously outside the neonatal intensive care unit (NICU) of a private hospital in Karachi. The woman is peeping inside, trying to catch a glimpse of her newborn. Soon, the wait is over. A nurse asks for the ‘mother’ to come inside the NICU. The woman stands stunned in disbelief. This is the first time someone has referred to her as a mother. With evident incredulity on her face and tears welling up, she enters the NICU. As soon as she holds her tiny baby in her arms, the floodgates open and a stream of tears gushes down the mother’s cheeks.

Over two years later, Javaria Javed retells the birth story of her daughter to me. She speaks about her struggles and journey to adoption so clearly and with such attention to detail that her story begins to play like a movie in my head. The star of the movie is Minha, Javed’s ‘miracle baby’. Javed named her baby Minha because she liked the name’s meaning — a gift from God.

Javed believes that Minha truly is a gift for her. The young mother previously had an ectopic pregnancy — a rare pregnancy complication in which the embryo attaches outside the uterus. The pregnancy ended with a miscarriage and kidney damage to Javed. Being a newly wedded woman in her twenties, the loss of her unborn baby and her deteriorating kidney health were devastating for her and her family. To make matters worse, she was also advised to avoid pregnancy for the foreseeable future.

Today, it is Minha who motivates Javed to keep going despite her ailments. A year ago, the young mother had a kidney transplant, which impacted her hip bone. She can barely move without assistance now. The doctors had seen this coming. But for a young woman who was healthy until she conceived, this was a hard reality to accept. Childlessness comes with its own set of challenges but it becomes more distressing when accompanied by other health issues. Javed kept switching gynaecologists and nephrologists in her quest to find someone who could offer her some hope.

Eventually, a doctor did give her hope, just not the kind she expected. During her recurring visits to the doctor, she was advised to consider adoption. While the idea clicked with her husband instantly, Javed shrugged it off at first. In our society, adopting a child comes with its own baggage. Today, Javed clearly thinks adoption was one of the best decisions she ever made. She cannot imagine her life without her little bundle of joy, her miracle gift from God.

THE ADOPTION QUESTION

Most couples who think about adoption in Pakistan are battling some sort of fertility problems. The World Health Organization (WHO) defines infertility as “a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse.” Primary infertility refers to couples who have never conceived while secondary infertility refers to couples who are unable to conceive after one year of unprotected intercourse following previous pregnancies.

Infertility affects up to 15 percent of reproductive-aged couples around the world. According to a study published in the Pakistan Journal of Social and Clinical Psychology in 2017, the infertility rate in Pakistan is higher and stands at around 22 percent — with four percent of these being cases of primary infertility and 18 percent being secondary infertility cases. In other words, one in five married couples in the country has some sort of fertility problems.

Even though the use of assisted reproductive technology (ART), such as in vitro fertilisation treatment (IVF) or intrauterine insemination (IUI) has helped millions of couples around the world to become parents, these treatments do not guarantee a successful pregnancy.

But despite the prevalence of the problem, couples dealing with infertility often find themselves alone and ill-informed about their options. While Javed had a doctor who suggested she consider adopting a child, not everyone has such guidance. Most doctors do not mention adoption as an option, and there is a lack of counselling, especially when couples are considering adopting a baby.

Although adoption is not a medical event, in many cases, gynaecologists find themselves at the centre of it because of their expertise in handling infertility, pregnancy and childbirth. The recently dissolved Pakistan Medical and Dental Council advised physicians to provide support to all parties involved in adoption. Their code of conduct had suggested that, “Doctors shall remember that, in cases of proposed adoption, there are several parties involved, all of whom need continued support and counselling. Pregnant women who are considering giving up their babies for adoption shall be helped to approach advisory bodies or attorneys as the circumstances may be.”

This is not the case in Pakistan alone. The Committee on Ethics of the American College of Obstetricians and Gynaecologists also urges physicians to provide free, accurate and unbiased information about adoption to “appropriate” patients. It elaborates that a discussion about adoption may be appropriate for patients who are infertile or for patients in whom pregnancy may be dangerous. The committee advises physicians to provide situation-appropriate information about infertility treatments, adoption and child-free living to the patient so they can make the correct decision.

TWO GENERATIONS

Farheen Effandi is in her early forties. She was only six months old when, in 1976, her parents came from the UK to Pakistan and adopted her. They had sought permission from the UK government for adopting a child from their native Pakistan. They raised their only child with a lot of love.

Today, Effandi is also lovingly raising one daughter like her parents. And like them, she too adopted her daughter. But even though Effandi was an adopted child herself, her road to adoption was not easy.

Effandi and her husband Omar Chaudari were married in 2004 and decided to visit a specialist after trying to conceive naturally for a few years. They were diagnosed with unexplained infertility. Effandi and Chaudari considered adopting a baby from Pakistan but, being based in Australia at the time, certain legal restrictions kept them from doing so.

Currently, Australia has an active inter-country adoption arrangement with 13 countries, referred to as partner countries, and does not accept adoption visa applications for children who have been adopted from Pakistan. Effandi says that, being from Pakistan, she and Chaudari knew how many babies are abandoned and thrown in the trash in their country, and so they wanted to adopt from Pakistan. But luck was not on their side. “We also requested [the Australian government] to let us adopt from Pakistan as an ad hoc adoption but we were denied,” Effandi tells Eos.

“After the diagnosis we went for an IVF [in vitro fertilisation treatment] but it didn’t work,” Effandi says. “Over the years, we ended up having four IVFs.” Even though the use of assisted reproductive technology (ART), such as IVF or intrauterine insemination (IUI) has helped millions of couples around the world to become parents, these treatments do not guarantee conception or successful pregnancy.

IVFs are reportedly becoming increasingly common in Pakistan too, but there is a lack of reliable data regarding the treatment. While the success ratio of fertility treatments in Pakistan cannot be determined due to the lack of statistics, according to findings provided at the European Society of Human Reproduction and Embryology’s annual meeting last year, women who undergo IVF have a 27.1 percent possibility of the procedure resulting in pregnancy.

Dr Sadiah Ahsan Pal, the medical director at the Concept Fertility Centre Pakistan, says that patients at the centre are clearly informed about the chances of the treatment failing beforehand. Still many patients opt for the treatment.

In an attempt to conquer their ordeal, infertile couples incur huge emotional, financial and physical costs during the years of seeking infertility treatment. Then there is the anxiety and depression. According to the Society for Assisted Reproductive Technology, patients have rated the stress of undergoing IVF treatment as more stressful than, or almost as stressful as, any other major life event, such as the death of a family member or separation or divorce.

Infertility also has a significant impact on women’s mental wellbeing. They experience a roller coaster of emotions such as anger, betrayal, guilt, sadness and even hope. The depression and anxiety multiplies manifold after the failure of fertility treatment. With each announcement of pregnancy and sight of someone else’s baby bump, a patient’s anxiety and stress can become overwhelming.

Infertility is a disease and it is not a shameful thing if you cannot have a child, Effandi says. People need to open their minds and hearts and educate themselves. Effandi got pregnant a few times but had early losses and miscarriages. “I was just broken. I felt drained emotionally and physically,” she says. “My body got battered and bruised with injections, hormones and losses. It took a toll on me emotionally. So I said to my husband I can’t do it anymore,” Effandi says.

Couples dealing with infertility often find themselves alone and ill-informed about their options... Most doctors do not mention adoption as an option, and there is a lack of counselling, especially when couples are considering adopting a baby.

Soon enough, Chaudari found a work opportunity in the Middle East and the couple relocated. Effandi started an early learning centre in Dubai, but working every day with children only reminded her of what she was missing. It was not long before she flew over to Pakistan to register for adoption. In 2015, she met Bilquis Edhi to complete the registration process. Surprisingly, the following day she received the good news.

“I still remember bursting into tears and jumping into the car,” Effandi says. “We went to the Edhi Centre and this little bundle was just placed in my arms,” says Effandi, her voice shaking as she speaks.

OPENNESS IS KEY

Effandi’s baby Amelia (Milley) is four now. Effandi has had conversations with her daughter about adoption. “I have told her that she did not grow inside mummy’s tummy but she grows in her heart,” she says. Amelia knows that “a very special lady” named Bilquis Edhi looked after her, until she found her a “special home”. Effandi has also shown Amelia videos of Bilquis Edhi and Edhi Centres.

Tahera Hasan, a lawyer and the founding director of the Imkaan Welfare Organisation, an organisation that attempts to deal with the issue of infanticide and abandonment of children in Pakistan, also advises parents to integrate adoption in the daily lives of their infants so it no longer remains an event. She recommends openness with children since they are toddlers, using age-appropriate language, tools and mechanisms, such as making their life book or a storybook. “There are books available which parents can read to their child to get some support,” she says.

Effandi also hopes to write a book specifically for Pakistani children about adoption. As a ‘miracle baby’ who went on to adopt a child, she thinks she has some insights to share. “This is something I want to do for my daughter and I hope it may help some other children and parents,” she says. Effandi knows firsthand just how tricky the road to adoption in Pakistan can be, and how Pakistani parents often find themselves without any support system at the critical juncture before adoption.

SUPPORT SYSTEMS

Like many who have been in a similar position, Javed was intimidated when the doctors first suggested she consider adoption. The decision would impact not only her and her husband’s lives, but that of a child. She feared she wouldn’t be able to love the child like her own blood and was afraid that her family members wouldn’t be able to embrace the child completely either. Her husband kept trying to reassure her, but her fears were not dispelled. It took her two more years to finally decide to take the plunge.

Fears like Javed’s are not uncommon. “Parents are at the deep end and they don’t know what will happen. This is a challenge in itself,” says Hasan. She says the social stigma related to adoption and the fear of the unknown haunts many parents. But in the 70 to 80 adoption cases that Hasan has processed as a lawyer, she has not observed a single case of bonding issues between the parents and the child.

“These thoughts can be laid to rest if prospective parents associate with people who have gone through [the same] process or a professional that can guide them,” Hasan says. But getting help during the decision-making stage is not easy.

Javed tells Eos that there was no one in her close circle who had adopted a child and who could help her deal with her reservations. She was also unaware of any professional support groups. “Had there been a professional to help me deal with my fears and clear all the confusions in my mind, I would not have wasted five precious years [without a child],” she says.

To help prospective parents fight their fears, Hasan runs the Karachi Adoption Resource Centre (KARC), a forum that was established in 2011 and is dedicated to providing information and support, ranging from pre-adoption consultancy to post-adoption counselling for both parents and children. KARC, according to their Facebook page, aims to “provide support, encouragement and information to adoptive families and families about to adopt; encourage families as they go through the adoption process; promote adoption education/awareness; and have regular get-togethers with adoptive families to provide a framework of support and sharing.”

“At the KARC and Imkaan Welfare Organisation, we are available for counselling, guidance and to answer any questions that parents might have,” Hasan says. Parents can leave a message at their Facebook pages, email or call for assistance.

Besides KARC, a Yahoo group called Pakistan Adoption also provides support to people looking for advice on adopting a child from Pakistan. But there’s only so much these groups can do. Indeed, many like Javed, are not even aware that such support systems exist.

THE LUCKY ONES

During the selection process at Imkaan, Hasan says, her organisation does not consider people who seem to consider adopting a child as a way to earn some ‘naiki’ (blessings). “Parents need children to complete their family more than children need parents,” she believes. “There are many desperate people waiting just to be parents and many more who have travelled across oceans, spent a huge amount of money and gone through rigorous processes only to be parents. We consider them,” she says. Hasan says she tries to keep a balance between local and international adoptions, giving equal importance to both international and local prospective parents.

Like Hasan, Dr Mubina Agboatwalla, chairperson of a Karachi-based NGO called HOPE (Health Oriented Preventive Education) receives many adoption requests. She says she gets around two requests via email every day. “The list of these childless couples is long,” Agboatwalla tells Eos. “People are now more open to adoptions, so childless couples are more forthcoming.”

Naila, a representative of the Anjuman Kashana-e-Atfal-o-Naunehal, an orphanage located in Karachi, is also in a similar situation. She receives at least three to four adoption-related calls on a daily basis — mostly from outside Pakistan. “There are about 15 to 16 people in waiting from the past six years,” she says. “The previous applications have been discarded.” She’s also had to turn away prospective parents who were in tears, pleading to be added to the list.

Other organisations like Edhi Foundation have strict criteria in place for parents considering adoption. According to the organisation’s child adoption form, only couples who have been married for 10-12 years are eligible to apply. Widows or couples with other children are also not allowed to apply.

Most people who are looking to adopt a child are looking for a newborn, Agboatwalla says. She also believes that it is better to give newborns for adoptions because they can bond with the adoptive family more easily. Older children start recognising their close contacts, and so it gets difficult for them to adjust in a new environment, she says.

HOPE follows a very meticulous process for adoption. “We need a full case study and family profile besides other details. Then we meet both the parents together and separately,” says Agboatwalla. “We visit the homes and check their references. After we are satisfied, we give the baby for adoption after fulfilling all the legal formalities.” Agboatwalla personally keeps in touch with the parents to follow the progress of the babies.

Javed considers herself extremely lucky to have become a mother just eight months after she started trying to adopt a baby. “There are some very lucky people who are blessed with their own children and there are those who are not,” she says. “And then God handpicks some people and makes them parents even when they cannot produce their own children — they are the luckiest,” she says. “I can’t thank God enough for choosing me to be a mother,” adds the young mother, who opted to quit her job and become a homemaker after Minha’s birth.

Javed speaks about the “life-changing call” with a spark in her voice and tears of joy in her eyes. Being a first-time mother, she was not aware of the supplies she should take to the hospital. Excited and confused, she called the hospital to ask if she had to bring something for the baby and they guided her about the essentials.

The overjoyed couple headed for the hospital two hours ahead of the given time and waited at a nearby restaurant restlessly. I can imagine the couple at the restaurant with one eye on their watches. As I listen to the young woman’s stories, I catch a glimpse of my own watch and realise it is time for me to leave. Even though I am unable to meet Javed’s miracle baby, by the end of our conversation I have a clear picture of Minha in my mind because of all the precise details that have been shared with me. When Javed shows me Minha’s photos, she looks exactly like I have been picturing her. A lean, energetic girl, with distinctive features. She has beautiful black eyes and a smile that can melt hearts, a prominent mole on her left eyebrow and tightly curled hair, which her mother alone can handle.

Javed’s mobile phone and laptop are full of pictures and videos of Minha. As I swipe through them she continues telling me stories about her daughter. She tells me how she planned Minha’s birth photoshoot; how she designed a pink dress and hired an event planner, and celebrated her first birthday while having three rounds of dialysis. She tells me how she joined a Facebook group only to learn to handle her child’s curly hair. She tells me how she kept delaying her kidney transplant only because Minha was a small baby at the time.

Javed is a strong advocate of child adoption now. She has also helped a close friend adopt a baby by addressing her concerns and guiding her through the process. She calls Minha the missing piece of the puzzle that completed her life in ways she could not imagine. Indeed, this is a feeling many parents are familiar with.

Both Effandi and Javed believe that a lot more awareness is needed in Pakistan when it comes to adoption. They are irked when someone commends them for ‘rescuing’ these children. Javed instantly corrects people making these comments. “[My daughter] may have gone to another family who would have loved to take care of her but we [got] lucky,” she says. “We are truly blessed to have them.” Meanwhile, Effandi says, “These children come into our lives and heal us. “The pain of all those years just evaporates. It’s like it didn’t ever happen. They bring smiles to our face, it’s magical.”

Header: Leea Contractor

The writer is a member of staff.

She tweets @Tanzeel09

Published in Dawn, EOS, January 26th, 2020