Pakistan, like many developing countries, faces significant challenges in meeting its development goals, especially related to women and girls’ reproductive health. Pakistan launched its family planning programme in early 1960s as part of General Ayub’s Five Year Plan (1960-1965) with ambitious indicators on family planning and fertility rate. The programme has evolved since then and grown considerably over the years, and in 1990, the government launched a comprehensive Population Welfare Programme which till date remains the major element in the provision of maternal and reproductive health services. In 1994, the government launched Family Planning and Primary Health Care programme to increase outreach of family planning and basic health care services to villages through Lady Health Workers (LHW). A comprehensive National Health Policy was approved by the cabinet in 2001 with an aim to strengthen the health care services at village and tehsil level through grassroots-level health care services such as Basic Health Units (BHU) and Lady Health Workers programmes and referral systems to link up BHUs with Tehsil-level hospitals. Later in 2005, in line with Pakistan’s commitments to Millennium Development Goals (MDGs), federal ministry of health launched the National Maternal, Neonatal, and Child Health (MNCH) programme to reduce maternal mortality and infant mortality (the programme was transferred to provinces after the 18th Amendment and devolution). Pakistan is also a signatory to International Conference on Population and Development (ICPD) Programme of Action (PoA), Family Planning 2020 (FP2020), and 2030 Sustainable Agenda/SDGs.

Since the launch of Pakistan’s family planning programme, there have been many improvements in terms of fertility rates and demand and supply of contraceptives and family planning services. For example, male participation in the existing family planning users has increased remarkably in recent years and an addition of 4 million family planning users has been observed in between 2007 and 2013. The policy and programme framework at federal and provincial level has been strengthened further with structural improvements as well as greater budgetary allocation, which demonstrates government’s political will towards its commitments to FP2020 and SDGs.

That said, significant gaps still remain in terms of provision of universal access to quality family planning and contraceptive services. According to the recent Population and Demographic Health Survey 2012-2013 (PDHS), Pakistan has an estimated 31 million married women of reproductive age, of which only 35.4 percent women are using any contraceptive method. An estimated 26% of these women use modern contraceptive methods (pills and IUDs) and 9.3% women use traditional methods e.g. withdrawal and fertility awareness[1]. 20.1% of married women of reproductive age (around 9 million women) have an unmet need for family planning[2]. These 9 million women include: A) those who were past users of family planning services but have quit using contraceptive methods; B) women who use traditional method but can be persuaded to use modern contraceptive methods; C) women have never used any family planning method. These variances in the uptake and demand for family planning methods among a high percentage of women has prompted research and analyses of root causes. A recent study on family planning landscape in Pakistan highlights that fear of side-effects of modern contraceptives along with lack of information are the key reasons why such a huge percentage of women are reluctant to use family planning methods. In order to find an effective solution to this issue, one needs to look deeper into the factors causing contraceptive users to quit it (category A).

Many of these women access contraceptive services through lady health workers (LHWs) who are only equipped to support women’s basic reproductive health and child health services including family planning services, treatment of minor illnesses with basic curative care, and provision of EPI services e.g. vaccination, etc. Unfortunately, LHWs are not trained to provide comprehensive information on contraceptive usage and for the management of side-effects, even if they are minor side effects. According to studies, many women who have reported quitting the use of contraceptives have also indicated that they did not have access to any healthcare provider when they experienced side-effects from contraceptives use. 75% of the households LHWs serve are located in remote rural areas with little or no primary health care services in the vicinity, making women’s access to public health facilities to seek medical support in case of side-effects almost impossible. While this impediment affects women in rural areas the most, it also has an impact on women living in urban and semi urban areas because services providers in private health facilities are not equipped with sufficient knowledge to deal with such cases. This leaves most women with no choice but to quit usage of contraceptives. The fear of side-effects also negatively influences the choices of other potential users of contraceptives. Cost of side-effects management is another major contributing factor as many women who receive birth control services from LHWs are poor. Many women who have never used a contraceptive indicate lack of information as one of the key reasons for this decision. Many women report that they do not know which method is most suitable for them as LHWs do not routinely inform them about the larger range of contraceptive methods. Most often, LHWs who are serving in remote areas do not receive adequate supply and are therefore not able to offer range of methods to their clients. Lack of awareness regarding contraceptive use is prevalent among males and it serves as a major barrier to family planning thereby putting the onus of birth control completely on women's shoulders.

In order to meet the indicators for its family planning and MNCH programs and to provide universal access to quality family planning services, the government needs to undertake structural reforms based on feedback received from former and current users of these services. The concept of “access to services” also needs to be redefined in the light of above-mentioned findings from various studies and qualitative data from the grassroots. It should be defined using the rights-framework i.e. what are the social and economic determinants which are causing barriers to access these services and affecting/limiting women’s choices; are women making truly informed decisions when choosing a particular type of family planning method and whether comprehensive information is being provided; do rural women in most remote areas have access to as many contraceptive methods as middle-income and urban women; do women have access to adequate health services in case they experience any side effects. All of these aspects should be at the core of government’s programme implementation strategies. LHWs should also do regular follow up with the women who are using their services and establish referral mechanisms with public health facilities in cases of side effects. The family planning programmes also need to reach out to the men of the family in order to shift the burden of birth control and family planning from women.

[1] Fertility awareness is a collection of methods using your body’s natural functioning to determine the days of the month you are most likely to get pregnant. The tracking of ovulation cycle is often also used as a birth control method. 

[2] Women with unmet need are those who are fecund and sexually active but are not using any method of contraception, and report not wanting any more children or wanting to delay the next child. The concept of unmet need points to the gap between women's reproductive intentions and their contraceptive behaviour. (WHO)