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Women should leave the hospital with a contraceptive

Pakistan must ensure that women are included in the family planning process

 Published: September 26, 2019

An Internally Displaced Pakistan woman from the North Waziristan tribal region carries her sick child. PHOTO: AFP

By Farahnaz Zahidi

Her backache is better, and she is feeling relieved for more than one reason. An hour ago, Azra got an Intrauterine Contraceptive Device (IUCD) which she calls a Challa (ring) inserted, with her own free will; the IUCD will potentially give her a break of five years from conceiving a child. This 30-plus years old mother of three, who does not know even her own exact age, knows well now that to remain healthy to look after her three children, and to possibly give birth to healthy children in the future, her body needs a break. Azra had come to the Naudero Rural Health Centre (RHC), District Larkana, Sindh, complaining of bleeding since eight days. This was her second miscarriage. The medical staff, after an ultrasound, told her she had been pregnant since nine weeks and her pregnancy could no longer be sustained. As her dilation and curettage (D&C) was performed, she also got the IUCD inserted. “My husband did not want me to use a permanent method of contraception as we may want to have children after a gap of some years,” she said. Muhammad Panjal, her husband, and Azra herself, mutually decided to go for a long-term contraceptive, an IUCD in their case. “One of our focuses presently is to encourage women to go for long-term contraceptives, like we did for Azra,” says Naghma, working for Pathfinder as a Technical Supervisor for the district of Larkana for Family Planning (FP) related initiatives. Azra is all praise for the staff at RHC who made her understand what was best for her and her family. “We counsel the patients mostly during the antenatal visits; this gives us enough time inform them about the various choices of contraceptives, their benefits, as well as side-effects if any. The decision, then, remains with the patient; she chooses, after discussing with her family, the FP method best suited for her,” says Dr Erum Siyal, working at RHC Naudero.

Dr Siyal explains why Post-partum family planning (PPFP) is a key focus for FP in areas like Naudero. “Once they leave the hospital after delivery, they rarely come back. Reasons are many. Lack of mobility, lack of resources to pay for transport to reach the hospital, lack of awareness – these are all deterrents,” she says.

Dr Azra Ahsan, a gynecologist and obstetrician with a special focus on family planning and maternal health, terms the focus on PPFP as being “extremely important’, adding that it is all the more important because the Contraceptive Prevalence Rate (CPR) is insufficient for effective family planning, which means people are not using enough FP methods. “The silver lining, however, is that women are coming to health facilities to have their babies in increasing numbers. This is a moment to seize and an opportunity not to be missed,” says Ahsan.

Grass root level initiatives like Naya Qadam, implemented by Pathfinder International, have an increased focus on access to post pregnancy family planning. Naya Qadam is a consortium of six organizations – Pathfinder, Aahung, Greenstar Social Marketing (GSM), National Committee on Maternal and Neonatal Health (NCMNH), IPAS and Shirkat Gah – working in six districts of Punjab and Sindh provinces. The objective is to increase access to high quality PPFP with a focus on young women (age 15-24) in Sindh and Punjab. Naya Qadam is introducing a multi-sectoral, counseling-centered, integrated life cycle approach to post-pregnancy service delivery. It aims to lessen the widening gap between service availability and unmet need by upgrading lady health workers, community midwives, and lady health visitors’ (LHVs) capacity to offer services through redesigning antenatal care as a lever for taking full advantage of the postpartum moment to offer FP.

Women like Azra go back to their villages after getting contraception, and become informal activists of FP, convincing their female friends and relatives to do the same. According to Dr Siyal “the awareness has increased and continues increasing at a fast pace”.

57-years-old Salma John from Jamshed Town, Garden East Karachi, has been working as a Lady Health Worker (LHW) since 2003. “Contraception should be carried out within 24 to 48 hours after delivery or DNC, and within ten minutes after the placenta is expelled. That is the best time to do it, otherwise most women do not come back for follow up.” John shares that condoms and pills still remain the most popular methods of contraception. Examples of modern methods include the pill, intrauterine devices, implants, injectables, and condoms. “With the help of Naya Qadam’s training sessions, we learn something new every time,” says, John, explaining how LHWs stay abreast with the latest developments in the field of FP. Each LHW, in John’s area, covers a population of 1000, which means she has to visit 100 to 150 houses. “Attitudes vary greatly across ethnicities and demographics matter a lot,” says John.

Experts predict that by 2030, Pakistan’s population will swell up 245 million, making it the 4th most populous nation in the world. According to the latest Pakistan Demographic and Health Survey (PDHS) 2017-18, 17 per cent of currently married women have an unmet need for family planning. If all married women who want to space or limit their children were to use a family planning method, the contraceptive prevalence rate (CPR) would increase from 34 percent to 52 percent. Only 34 percent of currently married women are using a contraceptive method either to space or to limit births.

Zahida Parveen, an LHW for District Okara, Punjab, sounds very hopeful. “Over 20 years as an LHW, I have visited thousands of houses, often visiting 15 houses a day. And I have seen how the awareness about family planning has grown exponentially. Initially people were so skeptical of LHWs visiting and counseling them, especially about FP, that they would not even touch the Paracetamol we sometimes gave them for pain or fever. The mother-in-laws in particular felt we are part of some sinister scheme to stop their daughters-in-law from having children, and want to stop their future generations from coming into this world,” she says. Now, she happily reports, even long-term contraceptives like IUCD are accepted as a choice by many women. The training she and other LHWs are receiving by Naya Qadam has taught them about newer forms of contraception too, like Levonorgestrel Implants – implantable subcutaneous contraceptive capsules – sold under brand names like Norplant and Jadelle. “It has taken years to win over the trust of these families; now they are open to the counseling services we provide for them,” says Parveen.

Social attitudes and changing mindsets remains one of the biggest challenges. Based on her experience of more than 15 years, John feels that attitudes towards FP have improved. “Now women are becoming aware enough to themselves giving permission to get contraceptives. However male involvement is still deep-rooted, as are the pressures of in-laws. One of the biggest tasks of LHWs is counseling the families,” she says.

“Women are raised in the community to accept patriarchy and gender inequality, letting go off their rights to choose for themselves. This further empowers men and other household figures, like mothers-in-law, to decide about potential size of families,” says Tabinda Sarosh, a women’s rights and reproductive health advocate, and currently the Country Director of Pathfinder International. In many families, desire to have sons results in increase in family size, and men make most decisions on health, economics and rights of family members, yet do not take responsibility for contraception, she explains. As someone who is running projects with the Government of Pakistan for quality services of FP, Sarosh feels that the most important solution to the problem is re-construction of the existing social and gender norms, by working from policy to communities, through multi-level and multi-sectoral interventions. “Combining health, education, gender, and micro-finance interventions to create an enabling environment for women to get equal opportunities in education, employment and health related decisions” is the baseline solution in her opinion.

Provincial governments are showing an upward swing, and the thrust on FP seems to have started to show improvement.

Minister for Health, Punjab, Dr Yasmin Rashid, is focusing especially on two areas as priority – Maternal Health and Child Health – says Dr Akhtar Rasheed, who works as Technical Lead for Family Planning and Nutrition, government of Punjab, assistant the province’s Minister for Health as Adviser. “We want family planning to become a means for improving maternal health by ensuring that women have a gap of at least three years between having children,” he says. 1195 basic health units are working 24/7 in Punjab, in addition RHCs, DHQ hospitals, and tehsil-level hospitals. “Our focus is on facilitating antenatal care and visits, and use this opportunity to counsel the women to go for long-term family planning,” says Rasheed.

Focal person of the Sindh FP2020 and Technical Adviser of the Costed Implementation Plan’s (CIP), Dr Talib Lashari, says that the CIP’s implementation in the province of Sindh is underway at a fast pace. The province of Sindh became the first province to come up with a roadmap, the CIP, for achieving FP2020 goals. “Our focus is on increasing and enhancing existing services. We have 72 Reproductive Health Service A Centres (RHS-A) located in DHQs that supply a full range of all kinds of contraceptive methods. A new choice among contraceptives that has been approved is an easy-to-use subcutaneous contraceptive injection that women can give to themselves to prevent pregnancies for short term like 3-months; it is called Sayana Press. This has been introduced in 17 districts already and will be introduced in another 12 districts by December. Our aim is to increase the CPR to 45% by 2020. Post the release of the latest PDHS, research conducted by departments under the CIP Secretariat shows that the CPR has already reached 34%. But to reach our target, we will have to work two fold,” says Lashari.

Both the Sindh government and Punjab government provide contraceptives free of cost. In Punjab, the government even gives women the facility of free pick up to reach the hospital for deliver free of cost to encourage them to deliver at proper health facilities.

What is a fresh spin on the strategy for FP is that to increase the contraceptive prevalence rate (CPR), the government of Sindh is now focusing on urban migratory population and slums. “For this the Karachi Urban Plan is being made. Part of the efforts is to counsel migratory communities in their own language. We are focusing on PPFP, and 1758 doctors are being trained across Sindh for it. Tertiary hospitals are also being looped in for FP efforts. Trainings are also being conducted for helping insert devices that release levonorgestrel for birth control,” says Lashari.  He adds that in Sindh the political commitment is a hundred percent. However, he accepts that while there are opportunities, there are challenges too, and much needs to be done. “We have a window of optimism due to the above steps being taken.”

“When a woman goes through the often traumatic experience of a miscarriage, an abortion, or childbirth, and especially if her pregnancy was not a desired one, she is more receptive to the idea of getting PPFP. By PPFP, I mean both post-partum family planning and post-pregnancy family planning. That is the best time to make sure she goes home with a contraceptive,” says Rasheed.

While modern methods are being introduced and both public and private sectors are working on increasing awareness about FP as well as working on supply of contraceptives, there is little that can be done to bring women back to the hospital once they leave. Thus, post pregnancy family planning remains the key. “The women should not only leave the hospital with a baby, but with a contraceptive too,” says Ahsan.

An abridged version of this article was published in The Express Tribune here.

Sexual reproductive health: Life lessons

Despite being a key issue, Pakistanis still whisper when it comes to sexual reproductive health. DESIGN : TALHA KHAN

“I was nine years old when I started sprouting. I was not made to wear a trainer. Mykhala (aunt) came to me and said ‘no one should know that you are growing up. I will teach you how to hide it.’” She took two big coins, placed them on my chest at the right spot, and tied a long piece of cloth over it tightly.‘Never let a man kiss you, otherwise you will become pregnant’, she said. I was nine! I recall my uncle kissing me on my cheek and me crying all night thinking now I was pregnant and God would never forgive me.” Saima*, an educated working woman from Karachi, is now 39, married, and a mother. Yet, she still feels that the way she looks at sexuality is not normal but is unable to alter her thinking. For the longest time, she could not fully enjoy physical intimacy with her husband either since there was a sense of guilt “as if it is something wrong,” she shares.

This sense of shame that society conditions into people when it comes to matters of the body starts very early on. The man at the grocery store will very deftly look away the moment a woman asks for sanitary napkins and pack them in a brown paper bag. Most Pakistani daughters will not ask their fathers to buy sanitary napkins for them. Menstruation comes as a shock to many Pakistani girls. With a still relatively young average age of marriage of women in Pakistan, many women and even men confess that they did not know enough details of the conjugal relationship till they got married. Zareen*, a USA-based doctor shares that despite having done her MBBS at the time of her wedding, her knowledge was so bookish that she knew almost nothing. “The experience was horrendous,” she says. “My ex-husband was also young at the time and his sources of information about sex had been very wrong. I think we were never able to develop a normal bond.” 

Shame shame

This halo of shame that surrounds any and everything that has to do with a young body morphing into adulthood has dire consequences. Yet, there is still immense reluctance about discussing the matter with young adults.

“Lack of awareness  pushes young people to reach out to any source of information out of curiosity,” says Maliha Zia Lari, lawyer and human rights activist. “Questioning sexuality at a certain age is a natural occurrence, but the social clamp down further fuels the curiosity. As a result, they do learn about it, but they learn it [the] wrong way.” In Lari’s experience, this leads to dangerous things like unnatural experimentation, and often with the wrong people. Even young males are exposed to the risk of contracting sexually transmitted diseases (STDs) or being emotionally exploited by ill-meaning men or women. Lari adds that this is one reason why human rights activists discourage early age marriages. “We teach people to be ashamed of our bodies, not to take ownership. A young mind has so many unanswered questions,” she says. Contrary to popular belief, research also proves that awareness about Sexual Reproductive Health (SRH) does not promote promiscuity in adolescents. In fact, it makes them more cautious.

‘The talk’

Survey of a cross section for this write-up reveals that most parents in Pakistan do not talk to their children about SRH, and if they do, the onus falls on the mothers. According to a study conducted by Marie Stopes Society in selected districts of Pakistan, the onset of menstruation was associated with anxiety in 47% girls as only 13% of them reported receiving information about puberty before the onset of menstruation.

Data from a 2013 baseline study conducted by Aahung (a non-profit organisation that concentrates on SRH) in four districts of Sindh, with adolescents as subjects, showed that only 34% adolescents would talk to their parents about pubertal issues. Nearly 49% of those questioned believed that AIDS is a curable disease, which means they were not aware of the possible dangers of unsafe sex either.

For Hira*, a mother of three, the experience was one typical for most Pakistani girls. “I came to know about puberty the day I had my first period. I went running to my mom who just told me that this happens to girls and that this is ganda khoon (bad blood) that needs to come out of the body. And I must not tell anyone about it as its one big secret,” she shares. She confesses that she learnt about feminine hygiene or issues related to puberty on a trial and error bases. “Only the basic information of how to use depilatory creams was provided, but nothing about when and where.” Her knowledge of the physical intimacy between men and women and how babies are born remained limited to that from Bollywood movies. “I thought you meet a boy, and then two roses dance together in a park, and you have a baby,” she laughs and says that she was told that “achi larkiyaan is baray mein baat nahi kartin”(nice girls don’t talk about these things).

“Once I begun menstruating, my mother would keep drumming one thing in our heads: do not commit adultery, it is one of the major sins,” shares 25-year-old Maria. Such a warning from mothers may not always be a bad idea. However, she acknowledges that her mother’s choice of words was harsh. “For the most part, I thank her for that. I have been tempted many times but never crossed a line and that has saved me from many an emotional disaster,” she admits. Maria’s idea of sex, however is so plagued by a sense of guilt that she fears she will feel guilty initially even with her husband after getting married. “It will take me time. But I would give the same training to my daughters,” she says.

Educationist and motivational speaker Abbas Hussain strongly endorses the practise of parents talking to children about SRH, albeit sensitively. Interestingly, Hussain feels that, “Urban mothers prove to be big prudes, whereas rural mothers see this very important part of human life as a part of nature. Such are the idiocies of urban life that a cow giving birth to a calf is not considered normal,” he adds.

Will daddy talk to his son?

“Fathers take very little interest in the sexual education of their children, even boys, as the common notion is uss key doston ney bata diya hoga (his friends must have told him). Men are generally shier then we think,” says Hira. “My father never talked to me about these things,” shares 20-year-old Shehryar Imran. However, he feels it is very important for adolescents to be adequately informed about the changes their bodies are going through “without having to rely on clandestine conversations with peers who also may not be fully informed,’” he says. “In order to combat the spread of STDs, it is imperative to target the root cause of the problem: breaking the unhealthy taboo surrounding sex.”

The ‘talk’ at school and choice of words

Hussain also stresses the importance of teachers’ role when it comes to SRH. “Senior teachers can play a huge role, but in this I am very clear about the gender segregation — male teachers for boys and female teachers for girls,” he says, adding that sensitive and cultural sensibilities need to be respected. He also stresses the importance of chosing words carefully. “Using the term ‘sex education’ deflects from the real issue; this term is the red herring,” he adds.

Maliha Noor, manager communications at Aahung, endorses using “culturally appropriate language.” Hence, Aahung’s successful awareness programme on the subject is called Life Skills Based Education (LSBE). “This should be included not just in school curriculum but even our medical practitioners in the making should be taught about this,” says Noor. “Often, doctors and nurses know the biological details but don’t know how to handle queries about it.” Aahung’s LSBE curriculum covers a range of issues including pubertal changes, gender discrimination, HIV / AIDS, protection from violence, peer pressure, rights within the nikah nama, and family planning. Part of the programme also concentrates on training teachers. “When students would talk to us about their issues, we would often not take them seriously and even joke about them,” confessed one of the teachers trained by Aahung. After the training, she has learnt how to handle these queries sensitively.

*Names have been changed to protect privacy.

Farahnaz Zahidi is a senior subeditor at The Express Tribune. She tweets @FarahnazZahidi

Published in The Express Tribune, Sunday Magazine, January 25th, 2015.