“I t is good to delay the first, postpone the second, and prevent the third”- Daya Chaudhary.
Interestingly, this is the stance taken by many intellectuals, politicians,health experts,and doctorsonthe significance of birth spacing. In Pakistan, efforts to promote Family Planning (FP) started in the 1960s, but favorable results have not manifested yet. One reason for this situation could be theisolation of policymaking from ground realities and lack ofinvolvement of those directly impacted by FPin the process, in particular women.
We live in a society where women and girls are generally perceived as merely passive targets or acceptors of contraception, and not rights holders with distinct needs and preferences. Whereas, on the contrary, their familiarity with both the challenges and solutions facing themselves as well as their communities when it comes to family planning, putsthem at the ideal place where their voices should be heard – loudly, clearly and repeatedly. Lack of attention to theirrequirementsis the most prominent missing link needed for enhancing Pakistan’s progress on the FP frontier.
With the country’s population set to double by 2050, it is essential that women’s requirements are brought to the policy table sooner rather than later
According to a 2008 cross-sectional study published in the Pakistan Journal of Medical Sciences,around 40% of the women interviewedin District Sukkur of Sindh province were not aware of the various modern contraceptive methods. The need for information, in terms of who should be targeted for increasing knowledge, what the topics should be and how the knowledge sharing should be done is, without doubt,the first missing link in the chain of events that can lead to increased adoption of FP services.
In this respect, reliance can be placedon mediums such as FM Radio, SMS messages, and pictorial brochures/leaflets/ posters for addressing information and awareness needs, especially for the large segment of illiterate women. The creation of FP information desks for women in public sector hospitals and training of Lady Health Workers (LHWs) in FP related client counseling, can further benefit the cause. The LHW program’s main goal was to promote birth spacing, but they have been overburdened with other tasks. Polio work has become a greater incentive for them than their original mission. Reverting the LHWs to their mandate will also greatly assist in filling the information/awareness needs of women. An innovative way of popularizing birth spacing and creating information about it, especially at the village level, could be through the involvement of local women like the seamstress who are frequently visited by others in the community and also enjoy a certain degree of respect and influence among the locals. They can be used in the same way that social media influencers promote a product.
With half of the country’s population living in rural settings, it is no wonder that, for a vast majority of women across Pakistan, reaching health facilities remains a significant challenge. In this context, the establishment of more FP centers, especially at the village level, and ensuring the availability of active ambulance service to take women to better-equipped centers or hospitals to benefit from FP services there, can help address the gap. Measures such as these will help resolve those missing links that prevent FP services from becoming available to a large section of society.
For women, lack of cooperation from husbands and in-laws for availing FP services serves as a further impediment. According to a 2003 study published in the Journal of Biosocial Sciences, mothers-in-laws play a vital role in family size decision-making.Another qualitative study from the September 2015 issue of International Journal for Reproductive Medicine, confirms the significance of husbands and mothers-in-law in family planning decision making. Not involving family members like husbands and mothers-in-law in the FP process is another significant missing link in Pakistan’s FP program. Here,a slight change in focus from counseling only women to slightly increasing the ambit and including their significant others can work wonders to pave the way for birth spacing in every home.
Similarly, measures directed at ensuring the uninterrupted provision of contraceptive methods can further contribute towardsimprovingthe situation. A stock management & distribution system available on the government’s health dashboard can help ensure continuous supply while also serving as a monitoring and accountability tool. Furthermore, specific methods, like the Levonorgestrel-relating implant,which is mostly available only in FP camps, can be made available throughout the year in all health facilities. In most of the FP programs, services are provided, but there is no record of who got the actual service. A consolidated and organized stock management & distribution system will enable the concerned managers at district level to trace the distribution of services and to hold the field workers accountable-another missing link.
The fact that available FP services are not in line with the perceived notions of quality also serves as a further deterrent. The absence of qualified healthcare providers and specialized doctors or their availability subject to a high price not affordable for all contributes to limited use of FP services.Despite having an increase in the number of female students in Pakistan’s medical schools, very few doctors go to work at the village level. Most of these doctors are from urban areas and prefer to stay there. In such cases, options such as Telehealth, which are increasingly become a popular choice in the post COVID world, need to be looked into for providing quality family planning care to all at their doorstep.Through such measures, issues such as timely and adequate management of side effects from the use of FP methods, which at times deter women from the continued use of these methods, can also be effectively resolved.
In a nutshell, addressing these missing link’s in the country’s family planning programs will address the real issues and yield better results. With the country’s population set to double by 2050, it is essential that women’s requirements are brought to the policy table sooner rather than later. Only when family planning interventions are designed with their substantive input, in line with their ground realities, and in keeping with the obstacles faced by them at every step of the way, will they be more impactful &sustainable.
The writer is a Policy Consultant with the Forum for Safe Motherhood