Islamabad - Although household-level obstacles to family planning adoption are on the decline, yet the women are discontinuing contraceptives due to issues of accessibility and side-effects even in semi-urban and urban areas.

A separate study “Investigating the Low Patterns of Modern Contraceptive Use in Pakistan” lunched by the Population Council highlights the main sources of obstacles in family planning adoption and continuation, from domestic hindrances through issues of access to problems in service provision at facilities and beyond.

The study indicates that the hindrance posed by husbands to family planning is waning in all provinces, particularly in Punjab and Sindh, where men are becoming more supportive of family planning, primarily because it can help avoid the economic burden of a large family.

“However, these changes are as yet less pronounced in Khyber Pakhtunkhwa (KP) and Balochistan, where cultural factors retain a relatively stronger influence on the role of men. At times, mother-in-laws and husbands do not support their wives in adopting family planning because of societal and tribal pressures to ‘prove their masculinity’ by producing more children, particularly sons.”

Religion is no longer the most significant factor in family planning decision-making and use. However, its inhibiting effect on contraceptive use has not vanished completely, particularly in KP, where it is still widely held that Islam does not allow family planning, it says.

Availability of services, infection prevention, management of side-effects, range of contraceptives available, stock of complete and essential IUCD kits and behaviour and counselling services are those issues that are faced by all provinces, including Punjab.

However, physical access is most difficult in Balochistan, due to the scattered population and large distances from facilities. It is also a challenge in KP, parts of which are rugged and prone to landslides.

Choices in contraceptive methods are very limited at department of health facilities, especially in Balochistan. In Sindh, lady health workers (LHWs) often lack stocks of all three methods, which further reduce choices for clients.

According to the latest Pakistan Demographic and Health Survey (PDHS 2012–13), 20 per cent of married women of reproductive age (MWRA) have an unmet need for contraception. Moreover, the country’s contraceptive prevalence rate (CPR), for modern and traditional methods put together, is only 35 — one of the lowest CPRs in the region. The study finds discontinuation to be driven mostly by perceptions and experiences of side-effects of modern contraceptives. “Women and men from communities as well as service providers list method-specific side effects that plague users, forcing them to switch methods, turn to traditional methods, and, at times, finding none safe or useful, opt out of family planning altogether.”

Women are discontinuing because of side-effects even in semi-urban and urban areas, where presumably there is relatively better access to healthcare providers, it highlights. “Side-effects are experienced more for injectable and IUCDs. Apart from the actual side effects, fear of side-effects and the personal, social and economic costs of living with side-effects also force women to discontinue contraceptive use.”

Heavy bleeding has been reported as the major side-effect of contraceptives in the study, which in turn leads to inability in performing household chores, taking care of children, offering prayers, maintaining marital relations, attending social gatherings, and managing the cost of side-effects.

The study recommends that coverage in under and unserved areas should be increased by delivering services at the doorstep through LHWs or other community-based workers, such as community midwives (CMWs).

The report also exhorts that local religious leaders should be involved and sensitised on family planning and be involved in family planning campaigns to support the need for policymakers to prioritise birth spacing from the religious perspective.

The study also suggests that provision of family planning counselling and services to potential clients during antenatal, natal and postnatal checkups, as well as during general health visits, be made mandatory by healthcare providers. The availability of supplies should be ensured in all health and population welfare service outlets. The departments must also focus on addressing discontinuation of family planning methods by clients on priority basis.