Determinants Associated With Unmet Need for Family Planning in Pakistan
The recent data in the Pakistan Demographic and Health Survey 2012-2013 shows a high unmet need for contraceptives, although family planning programs have been in place in Pakistan since the late 1950s. The phenomenon presents a complex picture, as the contraceptive prevalence rate has remained almost unchanged over the last 10 years. A number of determinants are responsible for the unmet need for family planning in Pakistan; making it a critical public health issue. This paper addresses the determinants of unmet needs for family planning and suggest some strategies and recommendations to reduce its impact on the community.
Introduction — Unmet need for family planning is defined as abstaining from the use of any contraceptive method despite being sexually active and a preference to delay or avoid future pregnancies . If people are given freedom of choice, many of them would prefer to limit their family size or to establish spacing between pregnancies so as to improve their standards of living . However, family planning programs in developing countries particularly Pakistan are inadequate to fulfill people’s needs.
Over a decade, family planning programs and services nearly remained unchanged due to the supply of, and demand for, family planning needs [3,4]. A number of determinants are responsible for the unmet need for family planning in Pakistan and for making it a critical public health issue. This paper addresses the determinants of unmet needs for family planning and suggest some strategies and recommendations to reduce its impact on the community.
Magnitude of the Problem: In developing countries, regardless of dramatic growth of contraceptive access globally, approximately 137 million women who prefer to avoid pregnancy are not able to do so . Pakistan is one of the most heavily populated countries with a growth rate of 2.0 ; although Pakistan was the first country in South Asia to introduce national family planning program, the prevalence of unmet need in Pakistan is the highest among all countries in the world .
According to the preliminary report of Pakistan Demographic and Health Survey , the Contraceptive Prevalence Rate (CPR) is 35%, which is a five percentage point increase from 2006-07. Out of these contraceptive users, only 26% use modern methods of contraception whereas 9% use traditional methods . With respect to the demands of contraceptive use, 55% women desire to practice family planning methods, but disappointingly, lack of services and family planning programs results in an unmet need of 25% . This population includes women who want to limit their family size or to space out their children.
Moreover, contraceptive use among currently married women is highest in Islamabad at a rate of 59%, followed by 41% in Punjab, 34% in Gilgit Baltistan, 30% in Sindh, and 28% in Khyber Pakhtunkuwa, with the lowest rate being 20% in Balochistan. This situation is alarming among the poorest, rural, and uneducated groups where 1 out of 4.1 Total Fertility Rate (TFR) is an unwanted pregnancy . In Pakistan, approximately 890,000 induced abortions take place annually, while 1 out of 7 pregnancies are aborted by induced abortion . Abortion is used as a birth control method to avoid unwanted pregnancies, and due to restrictive laws of abortion, it is usually carried out by unskilled and untrained providers under secret settings which results in severe outcomes ranging from lifetime morbidity to mortality, thus increasing the prevalence of maternal mortality . Therefore, this data represents the strong indication that many women desire to control their pregnancy but fail to use effective contraception.
The Phenomenon of Unmet Need and Millennium Development Goals: The phenomenon of unmet need for family planning includes married women refraining from the use of any modern or traditional contraceptive methods in spite of their wish to postpone pregnancy or to avoid childbearing . Family planning directly promotes millennium development goals (MDGs) from goals concerning gender quality, child health, maternal health, combating HIV/AIDS, environmental sustainability, and global partnerships. However, these can only be achieved by fulfilling MDG-1 i.e. ending poverty and hunger, and MDG-2 i.e. universal education .
Discussion — Socio-cultural determinants: The use of contraceptives depends upon dynamics of social organizations and social relations. In Pakistan, gender inequalities have greatly influenced the health of women with regard to reproductive burden resulting in excessive and early child-bearing. This issue has led to normal maternity being united with a variety of healthcare problems .
Although many researchers have claimed that awareness about family planning is universal among Pakistani people, PDHS (2006-07) revealed staggering findings, reporting that about 56% of women have never been exposed to any television or radio campaign related to family planning, while those who have heard of these programs considered them family limiting programs . Moreover, programs on family planning are also viewed as taboos, especially among rural populations. Due to this, people seek the advice of village elders, religious thinkers, and clergymen in society for family planning. Therefore, social approval from these people and transformation of the norms and beliefs of the community can fulfill the unmet need for family planning.
Women’s Autonomy: Men play an important role in deciding the health care needs of a woman. As decision-makers, they assume a position to decide where and when woman should look for healthcare services . Studies have shown that in order to seek consultation for family planning, lack of support from the family and mother-in-law makes the scenario worse. A woman is not allowed to take independent decisions for consultation to a service provider about family planning and is expected to reach the health facility only with the advice and permission of the head of the family . Certainly, this has severe consequences on the unmet need of family planning.
Furthermore, there is a clear link between a higher level of education and a smaller family size. Estimated, each year of girl’s education has been proven to reduce fertility rate by 0.3 to 0.5 children per woman . Unfortunately, in Pakistan, female literacy rate is very low overall (36%), and even lower in the rural population ; this reflects that education of women has a direct influence on contraceptive use. Nevertheless, in a survey of women who do not use any contraceptive methods, 58% women reported a desire for more children, 23% mentioned their husband’s restrictions on using contraceptives, and 12% reported fear and misconceptions regarding family planning methods .
Misconceptions about the Role of Religious Beliefs: The misconceptions and myths regarding contraceptives (mainly about pills, injectables, and intrauterine contraceptive devices or IUDs) are communicated quickly in closely-linked communities. In particular, religious resistance and misconceptions of family planning hinder the acceptance of contraceptives even among those who desperately want to avoid child-bearing or to space out their pregnancies. According to Hardee and Leahy, the most common hurdles for utilizing family planning among married women are: 28% have a faith that fertility should be determined by God, 23% women or men are reluctant or hesitate to use it because of perceived religious prohibition, 15% due to infertility and 12% due to concerns related to health, its side effects or the high cost of family planning services . To address these myths related to the use of modern contraceptives, strategies should aim to eradicate the negative religious perceptions, particularly among young married women .
Economical Determinant: Poverty restricts people from the benefits of health and also limits them from participating in decision-making, including that for family planning services, which results in a high unmet need and health inequalities. The financial polarity in the society and lack of security make the poor population more vulnerable in terms of choosing healthcare providers and affordability ; in many countries of South Asia and particularly in Pakistan, 76% of the health expenditure goes out-of-pocket . This situation leads people to avail poor-quality reproductive healthcare services such as traditional healers (dais and quakes) and is largely responsible for a low CPR, hence indicating cost as a foremost obstacle in pursuing appropriate health care in Pakistan. Furthermore, in Pakistan, there is a great impact of distance on the service utilization, which is multiplied when combined with the lack of transportation and damaged roads and contributes to increased cost visits .
Physical Accessibility: Poor quality and limited access to reproductive and family planning services are the main cause of high TFR and low CPR . According to the PDHS (2006-07) and its estimates regarding the prevalence of people utilizing family planning services, 48% consult public sector, 30% prefer private healthcare facilities, while 12% opt for non-formal or other service providers . However, approximately 10% either did not share the information or were not able to recall where they consulted for contraceptives .
Despite having massive Primary Health Care (PHC) setups, they are underutilized and deliver limited family planning services to the rural and semi-urban populations . Moreover, due to the lack of family planning service delivery outlets and the increase in population growth, pressure and demands are increasing on the existing ones. Also, these healthcare services lack professional and trained staff, and their insensitive attitudes are major obstacles for women to seek out family planning services .
Fortunately, the role of non-government organizations (NGO) has advanced since 2008. For instance, the Marie Stopes Society annually serves approximately 1.1 million women with family planning services. Other chief family planning NGOs in Pakistan consist of the Rahnuma, Family Planning Association of Pakistan (FPAP) and Green Star Social Marketing that cater to an additional 0.3-0.5 million women annually .
Public Health Strategies to Reduce the Impact: To reduce the impact of the unmet need for family planning in Pakistan, several strategies need to be implemented at different levels. Firstly, integration of family planning services with other first-level healthcare facilities is not only an existing demand but also an inexpensive and realistic way to reduce the unmet need. All Basic Health Units (BHU) and Rural Health Centres (RHC) should highlight family planning services as essential components of their basic package of healthcare services.
Secondly, a culturally sensitive communication strategy which includes information, education, communication, and behaviour change communication needs to be planned to motivate, empower and encourage women to transform their behaviour by addressing their apprehensions about family planning. Moreover, engaging older women at the community level and listening to their opinions about family planning may help overcome the prohibitions imposed on women. Also, including contented family planning consumers as ambassadors in the campaigns at the basic healthcare levels would portray family planning as an acceptable social norm.
Thirdly, private sectors which are involved in social marketing should subside in the prices of contraceptives so that to overcome the barrier associated with cost. More commercial sales of the most preferred method such as condoms should be encouraged. The ideal situation would also include improvement of the infrastructure to facilitate people’s access to the family planning centers. However, transporting these services to the doorstep by lady health workers (LHW) and public health nurses should be the main purpose of the national programs.
Most importantly, financing in girl’s education should be promoted, as it is not only a reliable strategy to improve women’s decision-making about contraceptive use and birth spacing but also to prompt healthier maternal and neonatal health results. Therefore, women development and youth development programs should work with health and population programs in order to develop meaningful strategies. Finally, role of media, especially campaigns, is important in raising awareness about family planning methods, significance of small family size and change in reproductive preferences. Effective crafted messages should therefore be promoted in communities.
Recommendations and Conclusion: In order to highlight the unmet need for family planning in today’s diverse healthcare system, determinants such as social and cultural constraints, geographical factors, economical and physical access to healthcare facilities, gender biases, women’s education, women’s positions in society, limited access to family planning services, and other factors related to the society at-large need to be explored. Moreover, there is a need to construct a more receptive and gender-sensitive healthcare system. If family planning program assisted most women with unmet need, a significant demographic influence would be seen, with a considerable decrease in fertility and a reduction in population growth. This has become, chiefly, the important requirement for poverty reduction along with social and economic development of Pakistan.
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