According to the latest Pakistan Demographic and Health Survey (PDHS 2012-13), 20% of married women of reproductive age (MWRA) have an unmet need for contraception. Moreover, the country’s contraceptive prevalence rate (CPR), for modern and traditional methods put together, is only 35%—one of the lowest CPRs in the region. (PDHS 2013-13).
Unfortunately, the issue does not end here. In addition to the problem of non-use, the country is finding it difficult to keep current users of contraceptives on board: compared to other developing countries, Pakistan has the highest rate of discontinuation of contraceptive use. Thus, as the graph below shows, while there has been an overall increase in the use of contraceptives—both in modern methods as well as ‘any,’ i.e., both modern and traditional methods—there is a large difference between the ever use of any method and current use.
PDHS 2012–13 made the disturbing finding that more than a third of women who had started using a contraceptive method in the preceding five years had stopped using it within 12 months. One in every five of these women had discontinued due to method-related reasons, including side effects, method
failure, dissatisfaction in use, lack of access, and affordability. According to Mahmood and Naz (2012), eliminating discontinuation due to side effects and method failure could increase continuation rates (at one year) in Pakistan by 10 percent and 6 percent, respectively.
This brief highlights the main sources of obstacles in family planning adoption and continuation, from domestic hindrances through issues of access to problems in service provision at facilities and beyond. The focus is on probing beyond traditional explanations with a holistic view to identify gaps in the demand for family planning care as well as its supply. We investigate not only the low use of contraceptives but also the alarmingly high rate of discontinuation. Policy recommendations are accordingly set forth.
The extraction for this brief is based on the findings of a national level study carried out by the Population Council in 2014 to investigate the reasons for low modern contraceptive use in Pakistan. Data for the study was collected from eight districts, including two from each of the four provinces, using a number of research tools that are outlined at the end of the brief.
For most couples in Pakistan, the intention to adopt family planning originates at home and is affected by domestic circumstances. A woman may feel a need to use contraceptives, but be unable to fulfill it because her husband does not communicate with her about family planning, or is averse to it. She may be confused as to the religious acceptability of family planning, or her in-laws might forbid it altogether. However, recent studies indicate that such household-level obstacles to family planning adoption are on the decline.
After overcoming the household-level issues that hinder their use of family planning services, women have to face another set of hurdles in accessing family planning services. The key issues are distance from services, transport problems and travel cost; timings of facility; and availability of female service providers.
With respect to household hindrances and access difficulties, the problems are much more severe in Balochistan and KP than in Punjab or Sindh. Religious clerics continue to exert a negative influence against family planning in KP. Persuaded by them, husbands and mother-in-laws discourage women from using contraceptives. Physical access is most difficult in Balochistan, due to the scattered population and large distances from facilities. It is also a challenge in KP, parts of which are rugged and prone to landslides.
Choices in contraceptive methods are very limited at Department of Health facilities, especially in Balochistan. Availability of services, infection prevention, management of side effects, range of contraceptives available, stock of complete and essential IUCD kits and behavior and counselling services are those issues that are faced by all provinces, including Punjab. In Sindh, LHWs often lack stocks of all three methods, which further reduce choices for clients.