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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.

Let us talk numbers – Contraception in Pakistan

For Pakistan to climb the ladder of development indicators, the issue of family planning needs urgent attention

Let us talk numbers
Only 34 percent of married women are using a contraceptive method.

While we are at it, let us talk more numbers. According to the latest Pakistan Demographic and Health Survey (PDHS) 2017-18, 52 percent of currently married women age 15-49 in Pakistan have a demand for family planning (FP), 19 percent for spacing births, and 33 percent for limiting births. Only 34 percent of currently married women are using a contraceptive method either to space or to limit births, and therefore have fulfilled their need. However, 17 percent of currently married women have an unmet need for family planning — 10 percent want to space and 8 percent desire to limit births but are currently not using any contraception. 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.

Humans require developed ecosystems to survive and thrive, something that we are unable to provide to more than 220 million people. Of the 17 Sustainable Development Goals (SDGs), Pakistan is lagging behind at most. According to UNICEF, 23 million children between the ages of 5 and 16 are out of school in Pakistan, a whopping 44 percent of the total population in this age group. There are some five million children between the ages of 5 to 9 who are not in school, making it the world’s second-highest number of out-of-school children (OOSC) at the primary level. Not just this but also that gender-wise, boys outnumber girls at every stage of education. In Balochistan alone, 78 percent of girls are out of school. For every 10.7 million boys that are enrolled at the primary level, 8.6 million girls are enrolled, and dropouts of female students remain high. Health experts say that over 44 percent of Pakistani children under five years are stunted due to chronic malnutrition.

It is not that Pakistan is not working on these issues. Yes, clearly, the work is not enough, but there is something more to the failing state of our social indicators. That is, perhaps, the missing link we do not see enough work being done on — family planning. The strapping Pakistani youth in such high numbers could be Pakistan’s asset; they are, instead, Pakistan’s Achilles heel. The nation has to not just feed the 220 million plus people. It also has to provide opportunities for growth and development so that Pakistani people can tap into their potential for economic prosperity of themselves and of the country.

The dots have been joined. Why, then, are we failing at it?

Lack of political will, and perhaps realisation among the upper echelons of power regarding the importance of mitigating this increase in population has been a consistent issue. Earlier this year, the Ministry of Health formulated an action plan for population control. The draft shows that the government is aiming at obtaining universal productive health services by 2025. The buck stops at the National Task Force on Population Control, headed by Prime Minister Imran Khan. But the real test is not just the approval of such action plans, but actually the implementation. The plans have been multiple but the implementation has clearly not been enough. When a country’s biggest issue has been its national security, followed if not preceded by layered and debilitating economic crises, family planning seems to be a lesser important challenge. In reality, it is one of the biggest ones.

What the proposed law is doing is updating an old piece of legislation with some new principles of human and women’s rights and ensuring that processes are made easier and more streamlined and that the suffering of a significant number of people in their country is reduced.

Healthcare persons and experts working at the grass root level cite many potential issues. While antenatal care and visits from a skilled healthcare provider may have improved, there is still much to be done. Midwives and lady health visitors can play an imperative role in this, and it is these programmes that need to be strengthened through their training and capacity-building. Perhaps this is why modern contraceptive use by married women has stagnated over the last 5 years, with 26 percent of women using a modern method in 2012-13 and 25 percent in 2017-18, according to the PDHS. Lady health workers play a major role in dispensing injectables, oral pills, and condoms to women, 18 percent, 26 percent, and 15 percent respectively.

Modern methods include injectables, intrauterine devices (IUDs), contraceptive pills, implants, male condoms, the standard days method, lactational amenorrhoea method, and emergency contraception.

69 percent of unplanned pregnancies end in induced abortion in Pakistan, states a recent study by Guttmacher Institute titled “Adding It Up: Costs and Benefits of Meeting the Contraceptive and Maternal and Newborn Health Needs of Women in Pakistan”. The study further informs that fully meeting married women’s need for contraception would lead to an estimated reduction of nearly 1,000 maternal deaths annually.

Contraceptive discontinuation, myths surrounding use of modern contraceptives, fear of side effects, lack of awareness, an absence of decisions made mutually by the couple without interference of mothers-in-law and societal dictates — the reasons are multiple.

World Contraception Day falls on the 26th of September. It is a reminder that for Pakistan’s well-being, much needed impetus for the issue of family planning is the solution. It is only then that Pakistan can hope to climb the rungs on the ladder of development indicators.

http://tns.thenews.com.pk/let-us-talk-numbers/#.XZGtB0YzbIU

 

A glimmer of hope for Sindh

Costed Implementation Plan is a right step forward in improving the state of family planning in Sindh

A glimmer of hope

As Pakistan’s second most populous province, with the population projected to increase to 61.7 million by the year 2030, Sindh has a lot to achieve. Out of a conservatively estimated population of 46 million, as per the Sindh Population Policy (SPP) 2016, a majority of which resides in urban areas, the actual population has the province bursting at the seams, with massive numbers of people migrating to Sindh, particularly the mega city Karachi.

The indexes are not encouraging. Sindh fares lower than the blue-eyed and better governed Punjab when indicators of both provinces are juxtaposed. The developmentally nascent Khyber-Pakhtunkhwa is also showing more promising upward trends.

Sindh has had successes, but numbered and calculated. While the Total Fertility Rate (TFR) declined from 5.1 births (in 1990-91) to 3.9 births (in 2012-13) in Sindh, the contraceptive prevalence rate (CPR) for Sindh seems to be stuck in a status quo at 29.5 per cent during 2001-2013. Though 96 per cent of the population is aware of at least one method of family planning, the unmet need for contraception in Sindh is still stuck at 21 per cent. In 2015, 13 million women were of reproductive age (ages 15–49), a number expected to rise to 15 million by 2020.

The SPP 2016 shares its high hopes and important but farfetched aims. One of them is to ensure contraceptive commodity security up to 80 per cent at all public service outlets by 2018, while another aims to increase access to Family Planning (FP) and reproductive health services to the most remote and farthest areas of the province by 2017. With almost three quarters of 2017 having passed, this is a good point in time to take a look at the state of family planning in Sindh.

At such a time, the Costed implementation Plan (CIP) promises a glimmer of hope — hope that is conditional to implementation. As a five-year actionable roadmap designed to help the Sindh government achieve its FP goals, the Sindh CIP can play a critical tool in achieving targets. Sindh is Pakistan’s first province to develop a CIP on family planning. The motivation, perhaps, is not just the challenges a large population puts in front of Sindh’s developmental efforts. The political will of late prime minister Benazir Bhutto still looms large as an influence over Sindh’s policy makers. “I dream of a Pakistan, of an Asia, of a World, where every pregnancy is planned and every child conceived is nurtured, loved, educated, and supported,” she once said.

Looking at data from Sindh, it is clear that one of the most important factors is increasing the awareness among the population. A case in point is that the two most frequently used FP methods in Sindh are female sterilisation and condoms.

The government of Sindh allocated PKR 890 million (US$8.5 million) during the last fiscal year (July 2015–June 2016) to CIP activities for 2015–2019. If the CIP, the cost of which is an estimated PKR 79.12 billion (US$ 781 million), does get implemented, the positive ramifications can be immense. It can have an impact not just on the FP efforts, but will also impact health, education, women’s empowerment, employment, as well as demographic and economic activities. Experts predict that if the proposed interventions are carried out, 1,848 maternal deaths and 29,470 child deaths could be averted by the year 2020. Some 1,774,367 unintended pregnancies and 193,332 unsafe abortions could be averted.

This is sorely needed. Earlier this year, Dr Talib Lashari, Technical Advisor, Costed Implementation Programme of Sindh Population Welfare Department, shared with members of the media that Sindh’s birth rate is 1,240,467 per year. This high birth rate, he commented, would not only result in poverty, but also in an insufficiency of resources available to the people of the province.

The estimated cost of the Sindh CIP includes an infrastructure upgrade and mass media campaign. These two aims will help increase awareness among not just the masses but also help sensitise on-ground staff, medical personnel and government officials towards FP. The hope, then, is to eventually reach a point that results in a change of the mindset and not just the numbers.

One of the key tools in the practical implementation of the CIP are the lady health workers (LHWs) who can play an effective role. LHWs carry out layered and multiple roles, and work on activities related to community awareness, maternal health, nutrition, immunisation, FP, as well as providing guidance on minor ailments and health education. They have access into the homes of their communities, and have social impact.

A weak infrastructure and social attitudes make mobility of women to the distant and numbered public health units difficult. LHWs fulfill the need to go door-to-door and convince the communities regarding FP. Pakistan’s FP 2020 commitment requires that the role of the LHWs in FP be enhanced. It is encouraging that the CIP team recently concluded that 50 per cent of allocations for the LHW Programme would be dedicated for family planning work, rather than the earlier 25 per cent.

Other important parts of this jigsaw puzzle that cannot be afforded to be missed are the Lady Health Visitor (LHVs), Community Midwives, Rural Health Centres (RHCs) and Basic Health Units (BHUs). There are some 22,575 LHWs and 770 Lady Health Supervisors (LHS) working in Sindh.

An exhaustive consultative process with stakeholders enabled the PWD and Department of Health (DOH) in identifying six strategic areas for investment in FP, all equally important. They are well planned out and focus on both increasing knowledge and awareness among the communities as well as better governance, improved coordination among the government departments working on it, and consistent government spending on this cause.

Looking at data from Sindh, it is clear that one of the most important factors is increasing the awareness among the population. A case in point is that the two most frequently used FP methods in Sindh are female sterilisation and condoms. While people are aware of short-term methods like condoms, pills and injections, the use of these methods remains low, and will remain low till the people are made aware and the contraceptives are made readily available. There are vast disparities in the provinces urban and rural development landscapes. The CPR rate in urban areas is of 42.7 per cent, compared to 17.4 per cent in rural areas.

If this province has any hope of attaining success with regards to the Sustainable Development Goals (SDGs) 2030, FP will have to be a key focus. It is hoped that the CIP fulfills its aims, and alongside effective FP, also positively impacts literacy and education in Sindh, as well women’s empowerment via increased work participation and economic self-sufficiency.

Would a ‘male pill’ revolutionise birth control in Pakistan?

Published: November 18, 2012

As Pakistan’s population time bomb ticks, contraceptive pills for men might become a game-changer. DESIGN: SAMRA AAMIR

KARACHI: 

With the world’s sixth largest population, and growing faster than the top five, Pakistan needs to drastically rethink contraception and family planning.

Until now, conception has largely been a man’s decision in a patriarchal society like Pakistan’s, but usage of contraceptives, when allowed by men, has largely been a woman’s responsibility.

That dynamic, however, may soon be turned on its head by the advent of the ‘male pill.’

The ticking bomb

The country’s headcount ticked past 180 million on World Population Day, July 11, 2012, according to the Population Census Organisation of the Government of Pakistan, and is expected to reach 300 million by 2050.

Fertility rates have been halved to 3.42 births per woman, from historic highs of 6.6 all the way up to the mid 1970s, but contraception usage is restricted.

Only 30% of married Pakistani women, however, use any form of contraception, according to the Pakistan Demographic and Health Survey, 2007. The percentage of men who use contraceptives is much lower.

That may simply be because of the variety of contraceptive options available to women – from pills and coils to injectables and rings – compared to only one accessible option for men, condoms. Even for that there is a lot of resistance. Vasectomy, for its invasiveness and non-reversibility, is not a popular option. In Pakistan, attitudes are also influenced by Islamic teachings that discourage permanent methods of contraception.

“According to Shariah [law] contraception is allowed if there is a genuine reason. But the methods allowed should be temporary and reversible and should not harm the user’s health. The reason should not be ‘who will feed them’,” said Mufti Shah Tafazzul Ali of Darul-uloom Karachi.

A contraceptive for men that is safe, non-invasive and with reversible effects may sound too good to be true, but is already in the making.

Herbal pill

While both allopathic and herbal versions of an oral male contraceptive are currently under research, the closest to hit the shelves is the pill from Indonesia.

Made from the shrub justicia gendarussa, which is found mostly in the Papua Island, the pill “disturbs the enzyme system of spermatozoa and affects its function,” according to Professor Bambang Prajogo, who started research on the world’s first non-hormonal contraceptive pill for males in 1987 at the Airlangga University in Surabaya, Indonesia.

In simpler words, the active ingredient from the herb weakens the sperm, disabling it from penetrating an ovum. The pill’s effect, meanwhile, is not permanent. According to findings of Dr Dyan Pramesti from Airlangga University, who held clinical trials, men were fertile again just two months after they stopped taking the pill.

The pill has been tested on mice for years, and has shown to be safe, effective and with few side effects, Professor Prajogo had said in an interview to PBS in July 2011. Clinical trials on humans had already started by then and, according to Prajogo, had shown “impressive results.”

The Gendarussa pill is ready to hit the Indonesian market in 2013, but will have to be approved by the World Health Organisation before it will be widely available elsewhere. Right now, a small-scale herbal medicine company called Naturoz has started the pill’s production. Once approved by international health authorities, it can easily be exported to Pakistan.

Under research

The latest news of an allopathic male pill has come out of Baylor College of Medicine in Houston, Texas.

Researchers discovered a compound, JQ1, that produces a rapid and reversible decrease in sperm count in mice.

According to a report from August 2012, the compound penetrates a boundary in the cells of the male testes and shuts off sperm development. The result is non-hormonal birth control that researchers said is entirely reversible. The research, however, is preliminary and clinical trials have yet to begin.

Revolutionising family planning

The idea of a male pill is being hailed by women’s groups, receptive males, and family planning advocates. The male pill would not only broaden the choice in contraceptives, but also change social attitudes towards family planning.

“Men being supportive, and involved in the choice, of a contraceptive method is the way forward. It would signal a behavioural change as currently men are generally a barrier to family planning,” said Dr Rehana Ahmed, a director at Greenstar Social Marketing, Pakistan and senior international health adviser to several NGOs.

“But behavioural change requires a process – pre-contemplation, then contemplation phase, and finally action. It is a slow process,” Dr Ahmed added.

Published in The Express Tribune, November 18th, 2012.

http://tribune.com.pk/story/467472/rethinking-contraception-would-a-male-pill-revolutionise-birth-control-in-pakistan/