Women in rural Pakistan champion the cause of population planning

KARACHI: Her father earns a meager Rs4000 a month as a gate keeper in the village school. Yet, this 18-year-old girl, whose biggest dream in life is to have her own computer, choses to do social work free of charge. “Anything that will help my people,” she says. She visits every home in the tiny village of Allan Chandio in district Shaheed Benazirabad, Sindh, convincing them to practice family planning (FP) and allowing their daughters to study so that they can make informed decisions about their lives.

“I even visit my uncles,” says Benazir Chandio with a broad smile. She does this in a culture where issues like contraception are brushed under the carpet. “They say you are too young to be teaching us. I reply that if God has given me more awareness than you, then I have every reason to teach you.”

Benazir, who has been given a well-deserved place in Shirkatgah’s “Building Momentum - Strengthening Champions" initiative, convinced two families to delay the weddings of their very young daughters. “Postponing those weddings for two years gave those girls some time to get ready for marriage and motherhood,” she says, and shares with pride that one of those girls recently gave birth to a baby girl at the right time. For women in her village, having anywhere between eight to 12 children is a norm. But she feels that with counseling, villagers are getting convinced to plan their families.

Standing at number six among the world’s most populous nations, Pakistan needs more such girls. In absence of satisfactory performance from the government, the onus to cause a change has fallen on the civil society.

Read: Addressing the baby boom: Women’s reproductive health an urgent issue

Experts like Country Director Population Council Zeba Sathar express dissatisfaction over Pakistan’s success in FP. “Pakistan’s performance in lowering its fertility is indeed dismal; while we had some success in the 90s, the last 15 years have been a virtual standstill,” says Sathar. According to the Pakistan Economic Survey 2014-15, Pakistan’s estimated population is over 191.71 million. While there seems a definite decline in Pakistan’s population growth rate (1.49 per cent in 2014, according to CIA’s World Fact Book), there is much to be done.

At the 2012 London Summit on Family Planning, Pakistan had committed to increase the contraceptive prevalence rate to 55 per cent by 2020.  Five years short of 2020, the world looks on to see if the commitment will be honoured. “Pakistan’s pledge at the London Summit is an opportunity, perhaps the last, to actually ratchet up efforts, drum up the political will and redesign the programs to accelerate family planning in Pakistan,” says Sathar.

Dr Azra Ahsan, technical consultant to the National committee for Maternal and Neonatal Health (NCMNH), says that health care providers need to be convinced first. “When they are not on board, how can we convince patients? What our medical students are taught is not relevant to ground realities. We know more about endoscopic and robotic surgeries, but our medical graduates don’t know about maternal health or public health policies.”

Ahsan adds that every health care provider should be trained to guide patients in FP. “Why is it just the gynecologist’s job? Between being referred from one specialist to another, patients slip away,” says Ahsan, and suggests that The World Health Organization’s (WHO) medical eligibility criteria (MEC) wheel should be on every doctor’s table. “It is such a simple guide advising which contraceptive is advisable for whom.”

Dr Farid Midhet, demographer and Country director Jhpiego, feels that one factor could be the general instability on many fronts in the country. “We are struggling with the same issues since the last two decades.” One thing that could work, according to Midhet, is integrating population planning into the public health system.

Talking about unmet needs of contraceptives, he says that the use of traditional methods of contraception have gone up by ten per cent, citing the latest PDHS results. However, traditional methods in his opinion are not reliable enough.

“A Population Council Pakistan research on Barriers to Contraceptive Use, 2013, shows that contrary to popular belief, neither religion nor male dominance are the main reasons for unmet need. Supply is the main factor here,” he says, adding that if supply is steady and is accompanied by counseling, use of contraceptives in Pakistan can go up by 50 per cent safely.

Sharing research showing the gap between what women want and the four million unwanted and mistimed pregnancies that are happening annually, Sathar says, “Two million of these end up in abortions, which could be avoided by better family planning programs.”

The aforementioned Population Council study confirms what most experts say – that Punjab is way ahead other provinces in terms of reaching developmental goals, including FP. “Punjab is the only province that may abide by its commitments in this regard. It is initiating the post-partum contraception program, which will be putting to use new technology,” says Midhet, adding that in comparison, Sindh faces more serious issues like lack of implementation of policies, corruption and shoddy governance.

Read: One death too many: One death in childbirth every 37 minutes

“The provinces are ready to play their role and have set ambitious goals for 2020,” says Sathar, expressing hope that the provincial governments now realize that they must set family planning as a priority. “While there are improvements in the budget lines for contraceptives (previously supplied by donors), funds and priority still lag behind.”

Conflict and insecurity has affected more than just health initiatives, with mental illnesses on the rise in Pakistan, especially in women, says Dr Rukhsana Ansari from Indus Hospital, Karachi. “It has a close link with inflation and poverty. Too many children exacerbate women’s problems,” she says, adding that mothers from underprivileged backgrounds suffer from nutritional deficiencies, muscular and skeletal diseases and sleep deprivation. In turn, the children they give birth to are also malnourished.

Mothers feel frustrated when they cannot go back to work because of their small children dependent on them, in situations where earning could alleviate their miseries. “If at all women chose to use contraception, the decision is not theirs. It is either the husband or the mother-in-law who decides.”

If the Lady Health Worker (LHW) program is re-focused on FP, it could yield results. Mehnaz is one such promising LHW. She has succeeded in convincing most households in the village of Kahazana Dheri, District Mardan, in Khyber-Pakhtunkhwa, to use contraceptives. “I can safely say that now at least half of the couples in our village are using contraception,” says the 36-years-old woman, another one of the Shirkatgah Champions. Yet, the obstacles are many. “Our area was devastated by the 2010 floods. Additionally, incidences of terrorism affect everything – when roads and bridges are blown off in bomb attacks, how will contraceptives reach small health facilities? People lose jobs in conflict areas. For an unemployed man, feeding his family becomes priority instead of buying contraceptives.”

Published in The Express Tribune, July 11^th, 2015.