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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

 

Emergency Contraceptive Pills: The misunderstood savior for Pakistan?

http://www.huffingtonpost.com/farahnaz-zahidi/emergency-contraceptive-p_b_9123750.html

02/01/2016 01:07 pm ET | Updated 10 hours ago

  • Farahnaz Zahidi Writer, editor, media trainer and communications expert.

2016-01-31-1454231905-8501237-kids.jpg

It does not work by means of abortion, has no effect on future fertility, does not increase risk of diseases like cancer or stroke, and will not harm a fetus or cause birth defects if a woman already happens to be pregnant. Yet, while the conventional 21 to 28 day contraceptive pill has found a degree of acceptance in Pakistan and most developing countries, the ECP (Emergency Contraceptive Pill) continues to be shadowed by myths.

Most people still confuse it for something that terminates a potential pregnancy, and thus confuse it with abortion. The facts could not be further from the truth. It is ironic that in Pakistan a lot of people avoid the ECP thinking that it translates into an abortion. Out of the 2.4 million unwanted pregnancies in Pakistan in 2002, some 900,000 were terminated by induced abortions (Studies in Family Planning 2007). These unsafe abortions that often claim the woman’s life due to resulting complications can be avoided with the use of an ECP.
This method of contraception can be used after unprotected sex when another form of contraception is unavailable or has failed. It can be used to prevent pregnancy for up to 120 hours (five days) after. Again, it acts as a preemptive measure, and does not cause abortions. The sooner it is taken, the better is the efficacy.

Why choose ECPs in Pakistan?
In Pakistan, it is available over the counter and unlike many other countries where it is a pricey contraceptive choice, it is economical. And it is safe. What is needed, then, is a more aware understanding about this excellent option.

As concerned world leaders, philanthropists, media persons and health care persons came together for the fourth International Conference on Family Planningheld in Bali, Indonesia, from 25 to 28 January, 2016, the ECP was discussed in depth. For the world’s sixth most populous nation even if the registered number of Pakistani citizens is considered, which stands at 199,085,847 in July 2015, as per the CIA Fact book, understanding contraceptive methods is vital.

In Pakistan, many organizations and pharmaceuticals, including Green Star andMarie Stopes facilitate the availability of and understanding about the ECPs. A section on emergency contraception in the Manual of National Standards for Family Planning Services, a document developed by the Family Advancement for Life and Health (FALAH) project, includes the EC and related policy. While the document recognizes that there is a lack of awareness among health care providers regarding ECPs, it also mentions certain stipulations about when it should be used and who should prescribe or dispense it. The possibility of it being used without misconception or difficulty, then, depends on how aware both the users and the health care providers are.

Representatives of the International Consortium for Emergency Contraception (ICEC) shed light on the subject during the ICFP. In over 140 countries women can buy emergency contraception and the ECP is readily available over the counter in 60 countries including Pakistan.


When the ECP is the best choice – in rape and other cases

While using a regular, ongoing method is recommended as the most effective way to prevent a pregnancy, in certain cases the ECP is the better choice. In cases of rape, it makes perfect sense. In 2013, the 57th Session of the United Nations Commission on the Status of Women stated that all Member States must require first responders to include EC provision in post-rape care. The ECP, thus, needs to be included as a regular post-rape treatment.

But the usage of the ECP should not be limited to cases of rape. It is also ideal in cases where the couple may not have regular sexual activity.

Most importantly, it bails out the couple, and especially the woman, in case of an “accident”. If she decides that this might not be the best time to have a child, the pill empowers her to use that discretion.

It is a safe, economical and effective method of contraception. It has very few side-effects and can be used more than once with the consultation of a doctor but should not be used as a regular contraceptive. To gain maximum benefits, people need to know more about what is often called the morning after pill. Above all, it need not be discussed in hushed tones. Contraception is a careful choice and Pakistanis need to make informed decisions regarding FP. Better to be more informed about the ECP and be safe than sorry.

So who should talk to the 20-somethings about contraception?

Published: January 27, 2016

The world is realising that due to cultural norms, adolescents and young people often do not discuss contraception with their elders or family members. PHOTO AFP

They can curse in each other’s presence, break traffic signals in unison and smoke together, and they may at times act macho and show off their romantic escapades. But young men, like their elders, do not readily open up about reproductive issues. Parents or teachers do not discuss subjects of a sensitive nature with them. While it is the same with adolescent and young women, they are comparatively more open to confiding in each other and getting guidance.

But it seems the world may be in for a change in attitude. Young men, all over the world, are stepping up to take part in reproductive discourse.

One such young man is Hamza Moghari. He is still reeling from the long journey from Deir El-Balah in Gaza, Palestine, to Bali, Indonesia. And the reason why he is there is that he has the guts to talk to his peers about difficult subjects like contraceptive choices and reproductive health. Hamza has seen more violence and difficulty than he deserved to in his tender age of 22 years. Coming to the International Family Planning Conference (ICFP) 2016 is a dream come true for him.

“This is the first time I sat on an airplane. I nearly never came,” he says, sharing the long journey of how he first reached Jordan from his home in Gaza.

He explained that he was sent away and told to go back due to lack of a no objection document, but he stayed near the border and went back the next morning, and was finally let into Jordan from where he flew to Bali.

A tad bit shy by nature, he confesses that the most difficult subject to talk about with boys his age is sexuality. Yet it seems that the world is realising that due to cultural norms, adolescents and young people often do not discuss these issues with their elders or family members. With their own age group, if they feel safe enough, they can talk about the typically hushed topics too. Y-PEER, a youth network of young people from more than 700 non-profit organisations and government agencies in more than 50 countries initiated by the United Nations Fund for Population Activities (UNFPA), uses an integrated approach to work with young people on subjects like gender, contraception and reproductive health. This year the thrust of all the discussions at ICFP was how to involve youth in the process. Half of the world’s population today, which is over 3.5 billion people, is under 30, mostly living in developing countries. They need guidance on these matters and silence may not be feasible anymore.

“If you’re not on the table you’re on the menu. How do we bring the youth on the table to talk about family planning?”

This question was put forth by Katja Iversen, CEO of Women Deliver, at the ICFP.

Pakistan is currently the world’s seventh most populous nation, according to the registered number of Pakistani, 199,085,847 in July 2015, as per the CIA FactbookContraception is thus an important subject that should be included in the nation’s narrative at all levels. In Pakistan too, this working via youth strategy has found a foothold.

One such initiative is Chanan Development Association (CDA). What started as a small theatre group is now an organisation that is youth-led and works for the youth.

Muhammad Shahzad, the executive director, has in tow young leaders wherever he goes. At the ICFP, too, he is watching out for and introducing proudly bright young people from Pakistan. One of them is 24-year-old Qaisar Roonjha, who says working with and for people his age is something he just has to do. His organisation, WANG (Welfare Association for Young Generation), is youth-led, and its primary focus is to struggle for a fairer society. Important buzz words like Youth Development, Women Empowerment, Mother and Child Health, Young Girls Education, Gender justice, Peace Promotion, Youth Development and livelihood security are all highlighted on the WANG website. From Lasbela in the perilous province of Balochistan, Qaisar has come a long way.

“I have met at least 40,000 young people all over Pakistan in the last five years,” he says with pride.

He shares that the toughest subject to tackle while talking to young people in Pakistan is gender equality.

“They still seem ready to discuss contraception. At least the married ones do. But seeing women as equal partners is difficult,” adds Shahzad.

Qaisar, whose video was selected for a competition held by organisers of the ICFP, attended the high profile conference in Bali as a moderator.

Ayesha Memon, an MBA student and youth leader from Hyderabad, also won the same recognition for her video, and addressed groups of interested activists and experts at the ICFP.

“Young people need to come out of their boxes; we should not assume things can’t change.”

Sharaf Boborakhimov is no novice at engaging with his peers on some of the trickiest subjects, which especially boys never openly talk about. Originally hailing from Tajikistan, he currently lives in Sofia, Bulgaria. This graduate in International Economy joined Y-Peer in 2011.

“What we do is provide safe spaces to youth where they can talk about sensitive subjects to people their own age. The peer-to-peer methodology works in tackling these subjects. We choose each word very carefully. We have to memorise manuals to know what to say and what not to and how to approach a subject.”

He has a close eye on the Syrian crisis, has Syrian friends, and has worked in Jordan closely with Syrian refugees who have made the Zaatari Camp their permanent home.

“We specially trained couples so that they could go back in the camps and train others. The refugees are just like any other couple. All they want is peace. They are depressed and frustrated no doubt. But in them I see a vision and a hope for a better tomorrow. They need guidance about contraception too.”

Theatre-based peer education, in Sharaf’s view is most effective for youth, whether they are refugees or not, the same strategy Chanan begun with.

“Since 2009, we have recruited some 50,000 young people for Y-Peer who work with us to educate their peers in important matters like sexual and reproductive health rights and also contraception,” Shahzad shares, adding that Pakistan was the first country in Asia Pacific that introduced UNFPA’s Y-Peer program in the region in 2009.

They are working with youth across 135 districts spread all over Pakistan including its toughest regions. In Pakistan, 65 per cent of the population is under 29, and 40 per cent fall into the even narrower age bracket of 10 to 24 years, says Shahzad.

“A big focus of our work is to engage with policymakers,” he says, sharing that Chanan was part of the National Task Force of 2009 for youth policy development, and is hosting the National Secretariat for Y-Peer in Pakistan.

For Hamza, the journey started by working for a local Palestinian organisation called Palestinian Family Planning and Protection Association (PFPPA). He is studying to get a degree in nursing.

“There are two million people in Gaza. The blockade is continuing since two years. Aid and medical help is almost impossible. Unemployment in my people is 70 per cent; among the youth it is 55 per cent. The healthcare system is fragmented. Very few people are able to reach the government-run healthcare centres.”

“In shelters that he has worked in, two to three thousand people were staying in one school. That meant each classroom was housing at least 50 people. Men, women and children, all strangers for each other, crammed into one room. With no food and water at least for the initial days till help started trickling in. Do you think family planning is a priority for them on a hungry stomach?”

In difficult situations and at such a young age, to be taken seriously and sensitise people about contraception is an uphill task. But these young people have realised that their generation’s reproductive choices will shape future demographic trends. They are thus helping their peers make informed decisions.