General attitude and awareness of people about

family planning in Pakistan

Introduction
Family planning allows individuals and couples to anticipate and attain their desired
number of children and the spacing and timing of their births. It is achieved through use
of contraceptive methods and the treatment of involuntary infertility. A womans ability to
space and limit her pregnancies has a direct impact on her health and well-being as well
as on the outcome of each pregnancy.
Family planning is sometimes used as a synonym for the use of birth control. however,
it often includes a wide variety of methods, and practices that are not birth control. It is
most usually applied to a female-male couple who wish to limit the number of children
they have and/or to control the timing of pregnancy (also known as spacing children).
Family planning may encompass sterilization, as well as abortion.
Family planning services are defined as "educational, comprehensive medical or social
activities which enable individuals, including minors, to determine freely the number and
spacing of their children and to select the means by which this may be achieved".
Health Impact
The WHO states about maternal health that:
"Maternal health refers to the health of women during pregnancy, childbirth and
the postpartum period. While motherhood is often a positive and fulfilling
experience, for too many women it is associated with suffering, ill-health and
even death."
About 99% of maternal deaths occur in developing countries; more than half occur
in sub-Saharan Africa and almost one third in South Asia.
Both early and late motherhood have increased risks. Young teenagers face a
higher risk of complications and death as a result of pregnancy. Waiting until the
mother is at least 18 years old before trying to have children improves maternal and
child health.
[11]
Also, if additional children are desired after a child is born; it is
healthier for the mother and the child to wait at least 2 years after the previous birth
before attempting to conceive (but not more than 5 years). After
a miscarriage or abortion, it is healthier to wait at least 6 months.
When planning a family, women should be aware that reproductive risks increase
with the age of the woman. Like older men, older women have a higher chance of
having a child with autism or Down syndrome, the chances of having multiple
births increases, which cause further late-pregnancy risks, they have an increased
chance of developing gestational diabetes, the need for a Caesarian section is
greater, older women's bodies are not as well-suited for delivering a baby. The risk
of prolonged labor is higher. Older mothers have a higher risk of a long labor, putting
the baby in distress. `
"Family planning benefits the health and well-being of women and families
throughout the world. Using contraception can help to avoid unwanted pregnancies
and space births; protect against STDs, including HIV/AIDS; and provide other
health benefits."

Contraceptive methods
According to World Health Organization (WHO)
Modern Method
Traditional Method
Modern methods

Method Description How it works
Effectiveness
to prevent
pregnancy Comments

Combined oral
contraceptives
(COCs) or the
pill
Contains two
hormones
(estrogen and
progestogen)
Prevents the
release of eggs
from the ovaries
(ovulation)
>99% with
correct and
consistent use
Reduces risk of
endometrial and
ovarian cancer;
should not be
taken while
breastfeeding

92% as
commonly
used

Progestogen-
only pills
(POPs) or "the
minipill"
Contains only
progestogen
hormone, not
estrogen
Thickens
cervical mucus
to block sperm
and egg from
meeting and
prevents
99% with
correct and
consistent use
Can be used
while
breastfeeding;
must be taken at
the same time
each day

9097% as
commonly
used

Method Description How it works
Effectiveness
to prevent
pregnancy Comments

ovulation
Implants
Small, flexible
rods or capsules
placed under the
skin of the upper
arm; contains
progestogen
hormone only
Same
mechanism as
POPs >99%
Health-care
provider must
insert and
remove; can be
used for 35
years depending
on implant;
irregular vaginal
bleeding common
but not harmful

Progestogen
only injectables
Injected into the
muscle every 2 or
3 months,
depending on
product
Same
mechanism as
POPs
>99% with
correct and
consistent use
Delayed return to
fertility (14
months) after use;
irregular vaginal
bleeding
common, but not
harmful

97% as
commonly
used

Monthly
injectable or
combined
injectable
contraceptives
(CIC)
Injected monthly
into the muscle,
contains estrogen
and progestogen
Same
mechanism as
COCs
>99% with
correct and
consistent use
Irregular vaginal
bleeding
common, but not
harmful

97% as
commonly
used

Intrauterine
device (IUD):
copper
containing
Small flexible
plastic device
containing copper
sleeves or wire
that is inserted
into the uterus
Copper
component
damages sperm
and prevents it
from meeting
the egg >99%
Longer and
heavier periods
during first
months of use are
common but not
harmful; can also
be used as
emergency
contraception

Intrauterine
device (IUD)
levonorgestrel
A T-shaped
plastic device
inserted into the
uterus that
steadily releases
small amounts of
levonorgestrel
Suppresses the
growth of the
lining of uterus
(endometrium) >99%
Reduces
menstrual cramps
and symptoms of
endometriosis;
amenorrhea (no
menstrual
bleeding) in a

Method Description How it works
Effectiveness
to prevent
pregnancy Comments

each day group of users
Male condoms
Sheaths or
coverings that fit
over a man's erect
penis
Forms a barrier
to prevent sperm
and egg from
meeting
98% with
correct and
consistent use
Also protects
against sexually
transmitted
infections,
including HIV

85% as
commonly
used

Female
condoms
Sheaths, or
linings, that fit
loosely inside a
woman's vagina,
made of thin,
transparent, soft
plastic film
Forms a barrier
to prevent sperm
and egg from
meeting
90% with
correct and
consistent use Also protects
against sexually
transmitted
infections,
including HIV

79% as
commonly
used

Male
sterilization
(vasectomy)
Permanent
contraception to
block or cut the
vas deferens tubes
that carry sperm
from the testicles
Keeps sperm out
of ejaculated
semen
>99% after 3
months semen
evaluation
3 months delay in
taking effect
while stored
sperm is still
present; does not
affect male sexual
performance;
voluntary and
informed choice
is essential

9798% with
no semen
evaluation

Female
sterilization
(tubal ligation)
Permanent
contraception to
block or cut the
fallopian tubes
Eggs are
blocked from
meeting sperm >99%
Voluntary and
informed choice
is essential

Lactational
amenorrhea
method (LAM)
Temporary
contraception for
new mothers
whose monthly
bleeding has not
returned; requires
exclusive
breastfeeding day
and night of an
infant less than 6
months old
Prevents the
release of eggs
from the ovaries
(ovulation)
99% with
correct and
consistent use
A temporary
family planning
method based on
the natural effect
of breastfeeding
on fertility

98% as
commonly
used

Emergency Progestogen-only Prevents Reduces risk Does not disrupt

Method Description How it works
Effectiveness
to prevent
pregnancy Comments

contraception
(levonorgestrel
1.5 mg)
pills taken to
prevent
pregnancy up to 5
days after
unprotected sex
ovulation of pregnancy
by 6090%
an already
existing
pregnancy


Traditional methods

Method Description How it works
Effectiveness
to prevent
pregnancy Comments

Withdrawal
(coitus
interruptus)
Man withdraws
his penis from his
partner's vagina,
and ejaculates
outside the
vagina, keeping
semen away from
her external
genitalia
Tries to keep
sperm out of the
woman's body,
preventing
fertilization
96% with
correct and
consistent use One of the least
effective methods,
because proper
timing of
withdrawal is often
difficult to
determine

73% as
commonly
used

Fertility
awareness
methods
(natural
family
planning or
periodic
abstinence)
Calendar-based
methods:
monitoring fertile
days in menstrual
cycle; symptom-
based methods:
monitoring
cervical mucus
and body
temperature
The couple
prevents
pregnancy by
avoiding
unprotected
vaginal sex
during most
fertile days,
usually by
abstaining or by
using condoms
95-97% with
correct and
consistent use
Can be used to
identify fertile days
by both women
who want to
become pregnant
and women who
want to avoid
pregnancy.
Correct, consistent
use requires
partner
cooperation.

75% as
commonly
used





Family Planning In Pakistan

Even though there is considerable demand for family planning in Pakistan, adoption
has been hampered by government neglect, lack of services and
misconceptions. Demographics play a large role in Pakistan's development and
security since the recent change from military rule to civilian leadership. Challenges
to Pakistani's well-being, opportunities for education and employment, and access to
health are escalated due to the country's continuously-growing population. It was
estimated in 2005 that Pakistan's population totaled 151 million; a number which
grows 1.9 percent annually, equaling a 2.9 million population growth per
year. Though Pakistan's fertility rates still exceed those of neighboring South Asian
countries with a total fertility rate at 4.1 (3.3 children in urban settings and 4.5
children in rural areas) and contraception use is lower than 35 percent, approximately
one-fourth of Pakistani women wish to either delay the birth of their next child or end
childbearing altogether.

According to Dr. Ansar Ali Khan, an advisor of reproductive health to the United
Nations Population Fund in Pakistan, "A combination of factors like non-availability of
services, baseless traditional beliefs and misconception play a big role." In addition,
Ali Khan stated that "a fairly large number of the population believes the use of
artificial contraceptives for family planning is against nature and also against
Islam."
]
Unlike Family Planning in Iran, a neighboring Islamic republic,
Pakistan's family planning program has failed in recent years due to neglect and
constant policy changes as a result of political upheaval. While 96 percent of married
women were reported to know about at least one method of contraception, only half
of them had ever used it.

History in Pakistan
In 1950, Pakistan's population reached 37 million people, making it the world's 13th
most populous country.
[1]
Though Pakistan was one of the first Asian countries to
begin a family planning program with some help from international donors, fertility
has declined slower than in neighboring countries. In 2007, Pakistan had increased
in world population ranking to 6th, with over 164 million people and the United
Nations (UN) has projected that in 2050 it will move into 5th place with around 292
million people.
Muslim populations are incredibly diverse, varying by race, language, and degree of
religious conservatism. Some populations are part of countries run by Islamic law, while
others live under secular governments. In Pakistan, extremely conservative Islamic
beliefs predominate in many parts of the country, in which purdah restricts women to
their homes unless chaperoned by a male relative. Additionally, levels of schooling are
very low in Pakistan, allowing men to have more power in decision-making.
When Ayub Khan was overthrown in 1969, religious demonstrators attempted to
discredit the leader morally using the slogan "Family planning, for those who want free
sex." This ideology is still present in Pakistan, as the organized religious party opposes
family planning because it is "un-Islamic". Though Pakistani couples commonly site
religious regions for avoiding birth control, there is not one definitive agreement about
family planning and contraception in Islam. In Pakistan, many local religious figures are
supportive of family planning and have begun discussions in their communities in order
to promote the health of women and children. Although many public health specialists
feel that religion plays a major role in resistance to the use of FP in Pakistan, the
Pakistan Demographic and Health Survey of 2006-7 showed that religious reasons
accounted for only 9% of FP non-use. In fact many NGOs have implemented
interventions where they have worked with local or national clergy. Research and
Development Solutions (www.resdev.org) reports that there is no quantitative evidence
that any of these interventions have resulted in an increase in CPR in these
communities.

Current Contraceptive Use in Pakistan
Historical political strife and cultural restrictions on women constraining their
empowerment have hampered implementation of family planning strategies throughout
the country. Most women who say they do not want any more children or would like to
wait a period of time before their next pregnancy do not have the contraceptive
resources available to them in order to do so. One-fourth of married women are
estimated to have an unmet need. In the 1990s, women increasingly reported to
wanting fewer children, and 24 percent of recent births were reported to be unwanted or
mistimed. The rate of unwanted pregnancies is higher for women living in poor or rural
environments; this is especially important since two-thirds of women live in rural
areas. While only 22 percent of pregnant married women report to be currently using a
modern method of birth control and 8 percent reported to be using a traditional method,
lack of widespread contraceptive use could be due to the lack breadth of the current
family planning program. The most commonly reported reasons for married women
electing not to use family planning methods include the belief that fertility should be
determined by God (28 percent); opposition to use by the woman, her husband, others
or a perceived religious prohibition (23 percent); infertility (15 percent); and concerns
about health, side effects or the cost of family planning (12 percent).
Private sector plays an important role in the provision of care of patients undergoing
abortions, as more than 60 per cent of all cases were treated by private sector
providers. Due to some legal restrictions and the lack of clarity among women and
healthcare providers in interpreting the law, women may be forced to seek abortion by
untrained providers. Approximately 700,000 women in Pakistan need treatment
annually for complications of induced or spontaneous abortion as a result.
Extending beyond the reach of family planning and contraceptive methods is the issue
of women's sexual and reproductive health. According to the Organization
and Population Action International, as of 2007, "only 16 percent of women receive at
least four antenatal care visits during pregnancy, less than one-third of births are
attended by skilled health personnel, and the maternal mortality ratio, at 320 maternal
deaths per 100,000 live births, remains high."


Case studies

Case#1
Couple Name: Zainab and Hussain
Age: 27
Years Married: 9 years
Blood Group: AB+
Location: Peshawar Rural Area
Children: 5
Risk Factor: High
Awareness about Family Planning: No
General Attitude: Religious approach about Family Planning as sin.
Education: Illiterate
Contraceptive Used: Pills Used
Zainab lives in rural area in joint family system with her husband and 8 children.
As Maternal Mortality in year 2010 was 260 as per 1 lakh in Pakistan
On one of these visits, Zainab approached the team and they counseled her on a range of modern
family planning methods, including condoms, the pill and long-acting and permanent methods. With
this knowledge, she made a life-changing decision and chose pills method.
Couple Name: Rehmat Bibi and Sikandar
Age: 36
Years Married: 18 years
Blood Group: B+
Location: Peshawar Rural Area
Children: 8
Risk Factor: High
Awareness about Family Planning: No
General Attitude: Not aware of Family Planning
Education: Illiterate
Contraceptive Used: No

Rehmat bibi lives in Peshawar rural area with her husband and eight children. The rate of unwanted
pregnancies is higher for women living in poor or rural environments; this is especially important
since two-thirds of women live in rural areas. While only 22 percent of pregnant married women
report to be currently using a modern method of birth control and 8 percent reported to be using a
traditional method, lack of widespread contraceptive use could be due to the lack breadth of the
current family planning program.
They're proud of their large family. Large families are common, but the risks are high. One in eight
women in rural areas dies during pregnancy and childbirth.
On one of these visits, Rehmat Bibi approached the team and they counseled her on a range of
modern family planning methods, including condoms, the pill and long-acting and permanent
methods. With this knowledge, she made a life-changing decision and chose a tubal ligation
The procedure took just 25 minutes and was performed under a local anesthetic. After the
procedure, she appeared fine and satisfied.

Rehmat bibi is one of the lucky ones. Millions of women still do not have access to modern
contraception and continue to die unnecessarily as a result of pregnancy and childbirth.









Couple Name: Shazia and Sultan Khan
Age: 29
Years Married: 5 years
Blood Group: AB+
Class: Upper Class
Location: Peshawar City
Children: 2
Risk Factor: No
Awareness about Family Planning: Yes
General Attitude: Positive approach toward family planning
Education: Literate
Contraceptive Used: Yes
Pills and Condoms (Traditional Method)
Now using IUD (Intra Uterine Device for five years)

















Couple Name: Mehwish and Mansoor
Age: 32
Years Married: 7 years
Blood Group: A+
Class: Upper Class
Location: Peshawar
Children: 2
Risk Factor: No
Awareness about Family Planning: Yes
Contraceptive Used: used Condom and family planning pills before but now using
Norplant
Norplant (chances of NOT getting pregnant): More than 99%)
Six capsules containing synthetic hormones inserted under the skin of your upper arm.
Capsules slowly release hormones into the bloodstream over a 5-year period.
These hormones stop the ovaries from releasing an egg each month.
Hormones also thicken mucus in the cervix (opening to the uterus), stopping sperm
from entering it.
Reversible method of birth control.
It is expensive method available in foreign countries.
Note that Couple applied this method in Ireland.


Raza Khattak Pharm-D
Session 2009-14