All cleaned up, his tiny head visible from under the colourful beret, the rest of the body wrapped tightly in a cloth, the new born was gently passed on to an elderly man standing outside in the passage of the labour room at KMC's Gizri Maternity Hospital. The mood is more solemn than of jubilation. The man leaned over and began reciting the Azaan loudly, first in one ear and then the other. The little one, his eyes wide open, listened to it intently. Five minutes later, another baby was brought out and handed over to the man and the ceremony was repeated.
Oblivious to that, just a few feet away, Shakila Ramzan, a reed of a woman shouted out 'Rabia ke saath' and minutes later a nervous-looking young man appeared, an older woman trailing behind him. The next half hour was spent by Ramzan trying to convince Muaqaddas Ali, 24, soon to become a father second time around, the advantages of family planning, and that too, soon after delivery.
With his wife Rabia soon to deliver, Ramzan had a small window of opportunity to get Ali's consent to allow the hospital administration to insert a T-shaped Intrauterine Contraceptive Device (IUCD) into his wife's uterus while she was still on the delivery table.
The couple didn't want any more children, but Ali seemed reluctant to have an IUCD inserted in her wife. They had refused during antenatal clinics which his 18-year old wife had been visiting regularly. "After our first child, we were told by the doctors at the previous hospital that this FP method was not suitable and may cause a lot of problems," Ali explained of his reluctance. He said they would decide after 40 days.
Gentle cajoling did the trick and Ali signed the consent form. "I have to talk so much every day, it's quite draining," said Ramzan, as she wiped the sweat off her face and straightened the dupatta over her head. She also said that if the long acting IUCD was not inserted immediately after delivery, women would have to wait six weeks. "During that period, she may get pregnant!"
In another part of town, in another hospital, the situation is similar. Maria Irfan, staff incharge at the government-run Sindh Empoyees Social Security Institution hospital in Landhi, is a trained counselor for LARC (long acting reversible contraceptive). "It's really difficult to convince husbands to give consent and sometimes we have to do it multiple times. It can be quite tiresome," she echoes Ramzan's woes.
Both feel, lack of education is a big curse. "If only these women were even slightly educated, our tasks would be made so much easier," said Ramzan.
Close by, waiting patiently to speak to Ramzan, was Rubina Sachal a mother of seven and having gone through 11 abortions. "Please remove the coil as I bleed heavily and suffer from severe pain in my back; and I'm gaining a lot of weight as well," requests an adamant Sachal. The women in the neighbourhood had scared her that the IUCD may have travelled up into her intestines.
Ramzan sat her down, addressed her complaints and convinced her to come back after a month while writing down a prescription for an iron supplement. "Take these tablets regularly and if you still suffer from these symptoms we will remove it," she told her gently with a reassuring smile, allaying the woman's fears.
Ramzan revealed that the woman had visited her twice before and she had been able to convince her not to get the contraception device removed. "If she does, she will get pregnant as her husband is idle and she won't take any precaution," she said knowingly.
"These women come with the weirdest misconceptions; and these would be hilarious if it were not so tragic. Even a little spotting will be exaggerated and considered bleeding," she said. Clearly the factors that she has had 11 abortions, seven births and that she is the only bread earner (the husband does not work) in the house are disregarded for her having health issues.
The PDHS (Pakistan Demographic and Health Survey) 2012–2013 states that twice as many women (28.3pc) from poorer households complain of side effects from Family Planning methods than wealthier women (14pc). The findings reflect poor quality of services (weak counseling about side effects and choice of method) at facilities serving the poor.
Ramzan said if something goes wrong with even one woman the method receives a bad reputation and its consequences spread like wildfire, not just in that neighbourhood but adjacent ones as well. By the same token the satisfaction and acceptance does not seem to spread as fast.
Pakistan just had its highly anticipated census and while the nation awaits its results, demographer Dr. Farid Midhet, heading the John Hopkins University affiliated international organisation Jhpiego in Pakistan, is certain there won't be too many surprises from results projected by various international organisations.
Right now the estimated population of the country is 195 million according to the United Nations (UN), making it the sixth most populous country in the world. By 2050, according to Population Reference Bureau, if things remain the same, Pakistan would remain in sixth position exceeding, 300 million people given its population growth rate.
Pakistan has one of the highest fertility rates in the region apart from Afghanistan and the lowest rate of contraceptive use (35pc) despite women showing an aversion to further procreation.
Dr. Zeba Sathar, Pakistan country director of the Population Council told Dawn.com that seven million women either don't want to bear more children or want to space births, but are unable to do so.
"They are unable to do so because of the lack of services or choice of contraceptives near or where they live," she explains, adding, "They also need more information and care regarding side effects to curb high discontinuation rates."
Sathar believes, "more choices of providers near their homes or community-based workers giving more than a few methods through task sharing, like lady health workers (LHWs) giving injectables in addition to pills and condoms would enhance choices instantly."
However, there are doctors like Azra Ahsan, a gynecologist and obstetrician with over two decades of dealing with patients from all strata of society, who believe Pakistan needs a more robust and sure shot way of tackling the runaway population.
They call it LARC - long acting reversible contraceptive, the same that Ramzan is promoting at the hospital in Gizri. There are two such methods - implants and IUCD, although Sathar also includes injectibles (which last for three months).
Although both IUCDs and implants have been around for a long time, even in the west they are not very popular because of past design flaws, difficult insertion and removal demands, or by the side effect and the bad reputation has stayed.
However, the new LARCs have come a long way according to Ahsan.
"The currently available LARC methods are easy to use, safe, long lasting and quickly reversible. In fact, they have fewer contraindications for use," she said, adding, "I'm all for it."
Ahsan, also the technical consultant at the Ministry of Health’s National Committee for Maternal & Neonatal Health (NCMNH) clearly favoured inserting IUCDs right after delivery leaving nothing to chance before the mother left the hospital. She says this post-labour procedure, which is done as soon as 10 minutes after delivery, is not difficult or risky, just different. "But imagine the woman can become stress free for as long as 12 years in the case of an IUCD and five years for an implant!"
Concurring with Ahsan, Dr. Midhet added, "LARC can help lower the rate of unintended (both mistimed and unwanted births); it gives the mother time to recuperate after a birth and provides an opportunity to the newborn to be breastfed, thereby prevent stunting and malnourishment." In Sindh, 48pc of children under five suffer from stunting and 15pc from wasting.
Senior technical advisor in Pakistan for Pathfinder, Dr. Tauseef Ahmed, also finds that LARCs provide the "best option" in terms of impact and also in terms of client satisfaction.
In Pakistan, he said, tubal ligation (more commonly known as female sterilisation) and condoms which are more popular, have not proven to have any impact on fertility. "Tubal ligation is preferred by women who have already produced 6-7 children, while condoms [are] associated with inefficacy."
Pathfinder is working with all provincial governments to create costed implementation plan— a five-year clear roadmap for achieving their goals for contraception.
With more and more women delivering at hospitals (the latest Pakistan Demographic and Health Survey of 2012-13 says it's 48pc) it perhaps gives healthcare providers that perfect but small window of opportunity to promote this method.
The reason for the urgency to start women on some form of contraception has been felt for some time. In the past doctors usually waited to discuss an IUCD or implant until a woman’s first postnatal checkup, six weeks after delivery. But, Ahsan conveys that most women never show up for this exam.
A recent study conducted in two hospitals in Karachi and Dadu, where over 3,000 women were interviewed, tried to find the reasons behind the high rate (38.2) of unintended pregnancies amongst women attending antenatal clinics in Pakistan and the factors related to FP.
The study found that 89.9pc women had knowledge about at least one of the contraceptive methods, but only 33.4pc reported using them with the most common being condoms (19pc) followed by injectables (9.7pc), the pill (9.6pc), intra uterine device (2.9pc), and implants (2.5pc) among modern methods. Among traditional methods only 14.5pc and 34.5pc of women had knowledge about the rhythm and withdrawal methods, while 13.8pc and 46.1pc of women reported using the rhythm method and withdrawal method respectively.
Unintended pregnancy in Pakistan, pointed the study, was higher among women who were younger, poorer, illiterate and living in a rural setting. Often the interval between pregnancies was less than 12 months, and they often had previous history of miscarriage or abortion.
"It makes sense since younger women have higher fertility, higher frequency of sexual intercourse, lower knowledge of contraceptive methods and higher rates of contraceptive failure relative to older women," said Dr Atif Habib, one of the authors of the study, speaking to Dawn.com.
Most unintended pregnancies result in abortions. Abortion is illegal in Pakistan and only permissible to save a woman's life or to provide “necessary treatment” early in pregnancy. Because the law is unclear and healthcare providers have their own personal beliefs, safe abortion services are difficult to obtain and most women who want it carried out resort to clandestine, and unsafe procedures.
A Population Council report noted that in 2012, there were approximately nine million pregnancies in Pakistan, of which 4.2 million were unintended. Of these unintended pregnancies, 54pc resulted in induced abortions and 34pc in unplanned births.
For this very reason, states Dr. Habib's study, over a 5-year period, even if 4pc women switch from current oral contraceptive use to LARC, 25,000 unintended pregnancies and their related abortions and unplanned births can be averted.
Ramzan sees almost two to three cases of post abortion complications daily and she convinces them to get the post partum IUCD inserted to save them from another abortion.
Same is the case at the Landhi hospital. Altaf expresses that while couples think nothing of getting several abortions done to terminate pregnancies, when it comes to using FP they say it's a sin since children are God's gift to them.
In her hospital, unlike in Gizri, implants are more popular. Just in May, she was able to convince 60 women to use this method while only six women were ready for PPIUCD.
Almost five years have passed since LARC has been promoted widely by various organisations and the acceptance rate, is growing. Dr. Laila Shah, director of the Sukh Initiative at Jhpiego is also promoting LARC in 42 public health facility hospitals in four towns of Karachi.
"It's a relatively a new concept in Pakistan, but due to the convenience it's gaining traction, since women don't have to return for FP service. In addition, fewer side effects are experienced in long term protection, she said. In the four towns they are working in, 30pc of delivered women opted for either implants or IUCD.
"I think we need to give credit to the counselors, especially those in labour rooms; they have indeed played a very important role and if we need to make further progress, this brigade of women are key."
For encouraging women to opt for LARC, Shah said dedicated counselors are deputed at selected mother and child health facilities in antenatal clinics and labour rooms.
At the same time, "we need more counselors," said Dr Ahsan and not just in the day time. "Many deliveries take place in the night when there is no one to counsel the woman and her family. Since FP comes under the Population Welfare Department (PWD) and deliveries happen in hospitals, which comes under health department, there remains a huge gap.
Another problem is that till the NGOs oversee counseling and insertion of LARC at government hospitals, the number of women consenting to LARC keeps growing. "But the moment we try to wean ourselves away, the numbers begin to fall drastically," observed Ahsan. She lamented that LARC had not been institutionalised in the manner that it should.
But Shah has a solution. She said the Family Welfare Centres (FWC) run by the PWD and the Reproductive Health Centres (also working under PWD) within the tertiary hospitals can easily be trained and accommodated in wards, since fewer couples visit these centres. In any case they close by 2pm. In Sindh alone, there are about 1,000 FWCs, but only 40pc are functional informed Midhet.
The economics of the situation also poses a problem. The upfront cost is far more expensive than the pills or condoms. But, Shah says, "the cost is covered by the government at their hospitals." "In any case," she went on to reassure, "compared to other methods, LARC is more cost-effective in the long-term."
However, Dr Ahmed of Pathfinder feels LARC has its limitations as not everyone can insert or remove these. "It needs technical competence as well as quality counseling and follow up for managing and treatment of side effects."
For LARC to be successful and have an impact governments hospitals, doctors, midwives as well as counselors all need to go that extra mile. That means training doctors, availability of counseling 24/7 and reassuring patients that if they ever have misgivings, they can come and have the device removed.
To read more about the situation in Sindh and frequently asked questions click on the tabs below.
In 2012, Pakistan along with 68 of the poorest countries made a global commitment to increase contraceptive use among women in those countries at a summit held in London, called the FP2020 . Compared to 2012, there are now 30.2 million additional users of modern methods, which is 25% higher. And though significant, it is still 19.2 million users short of the pace needed to reach the goal of 120 million additional users by 2020.
As a result of the summit, Pakistan made several promises aimed at increasing access to and use of family planning to constrain the growth of its population. These are referred to as Pakistan’s FP2020 commitments. Because health is a provincial subject after the 18th amendment in 2010, provincial goals had to be set.
The 2017 London Summit on Family Planning will be held in London, United Kingdom on July 11, under the shadow of the "global gag rule" imposed by the US that prohibits US organisations from assisting aid to foreign organizations that work on abortion counseling, referrals or services which would mean a cut the equivalent of about $600 million in family planning aid.
With all the provinces having their own population policies, Sindh government is the only one that has come up with an approved operational tool to breathe life into the policy. Termed Costed Implementation Plan (CIP), it is worth Rs141bn for five years.
According to Dr Ahmed, in Sindh, the number of implants served during 2015 and 2016 and now 2017 has reached 60,000. "Credit for this goes to Dr Azra Pechuho," he said, adding: "...and the coordination and zeal shown by the Pakistan Primary Health Initiative (PPHI) for pursuing implants after training all the doctors at all basic health units across the province."
In Sindh, there are currently 13 million women of reproductive age, and this number is estimated to reach 15 million by 2020. The total fertility rate in Sindh has declined from 5.1 births in 1990–1991 to 3.9 births in 2012–2013, while the CPR has been stagnant at 29.5pc, with 24pc of women using modern methods of contraception for over a decade. The disparities in the province are visible with 42.7pc CPR in urban areas and 17.4pc in rural areas, while unmet need remains at 21pc.
Sindh’s population is projected to increase to 50 million by 2020. There are 1.747 million married women of reproductive age (MWRA) who are the current users of contraception. The users of modern methods of contraception are projected to rise to approximately 3 million by 2020. Therefore, the province of Sindh should expect 1.298 million additional users of modern methods.
Both the public and private sectors are contributing towards provision of contraceptive services. An estimated 45pc of contraceptives are provided by the public sector. The two major sources within public sector are the Population Welfare Department (PWD) and the Department of Health (DOH). The private sector nongovernmental organizations (NGOs) provide 20.5pc of contraceptives; private pharmacies and chemists provide 25.3pc; private doctors contribute 2.1pc; while shops provide 6.5pc of the contraceptives.
Thus, the combined share of private sector is estimated to be 54.4pc. The PWD provides the services through its static and outreach facilities. Likewise, the DOH and People’s Primary Healthcare Initiative (PPHI) provide FP services through the static setup and through the massive network of community health workers—the lady health workers (LHW).
To increase access and uptake of FP in Sindh, there are quite a number of areas of concern that need to be addressed. Through a consultative process with key stakeholders, PWD and DOH identified broad priorities to develop six strategic areas for investment in FP. The CIP presents the strategic areas and the rationale for their selection, along with associated costs. The strategic areas are:
These strategic areas are guided by three principles (1) strengthening existing systems and services; (2) accelerating interventions; and (3) innovating proving ideas, bearing high-impact practices and modern technologies.
In order to achieve the following three objectives:
Implementing the CIP over the next five years will have a significant impact on health, demographic and economic activities. As a result of determined action on the proposed interventions, an estimated 1,848 maternal deaths and 29,470 child deaths will be averted by the year 2020.
Regarding demographic impact, an estimated 1,774,367 unintended pregnancies and 193,332 unsafe abortions will be averted, while PKR 12.187 billion will be saved by implementing the CIP, as an estimated 3,963,060 couple years of protection will be generated.
Punjab's CIP is also ready and is expected to be approved by the end of June or early July, Khyber Pakhutunkhwa's awaits a signal from the chief minister for a briefing (may get approved before the London Summit), and Balochistan should be ready to be presented to the chief minister by August.
To read more about family planning and frequently asked questions click on the tabs below.
Everything you always wanted to know about LARC but were afraid to ask.
Dr. Farid Midhet, who heads Jhpiego in Pakistan, responds to some questions women may have concerning LARC.
Affiliated with Johns Hopkins University, Jhpiego is an international non-profit organisation geared towards providing technical support and training in family planning, and improving maternal and child health in Pakistan for over 15 years.
Currently Jhpiego is taking the lead in institutionalising postpartum family planning across all provinces.
1. I'm in my 40s and our family is complete. I'm thinking of having a coil fitted but have heard scary stuff. Should I go for sterlisation instead?
For you, choices could be, implant and IUCD as both are long term methods and provide protection from 5 to 12 years respectively. While vasectomy and female sterilization are permanent methods and could be a possible option. Mirena is also good for pre-menopausal women.
2. I've also heard of implants. My concern is that it may release certain hormones and then the idea of having some metal inserted under my skin makes me uneasy.
There is no metal in implant, it’s a plastic devise with hormone(progesterone) and will not cause any discomfort due to elasticity of its rods. The side effects such as bleeding and spotting may occur in initial few weeks but are clinically insignificant and reduce considerably with time and without any treatment. However, insertion of implants requires service from a trained provider.
3. Between the IUCD and the implants which is more cost effective? Which is more foolproof?
In the Pakistani context, both should be available to women free of cost (or at a highly subsidized cost); therefore, cost is probably not an issue. However, implants are roughly 2-3 times more expensive than an IUCD in terms of manufacturing price. Both are about the same in terms of effectiveness, although hormonal IUCD is slightly more effective. No contraceptive method (except abstinence and removal of the uterus) is 100pc ‘foolproof’!
4. I'm in my late 30s and going to have my second child. After that we don't want to have any more children, at least for a while. I've heard of post partum IUCD. Is it safe to have something inserted so soon after delivery? I will be feeding my newborn.
Postpartum family planning IUCD (PPIUCD) and implants (IPPI) are two long term contraceptive that can be given right away after delivery without affecting breast milk. Both methods are extremely safe and effective with fewer side effects. The benefits far outweigh the potential risks and inconvenience. Both methods require a trained health care provider.
5. I'm in my late 30s, and have been told by my friends that I am too old for the pill which I have now been taking for almost eight years?
If you do not smoke, do not have high blood pressure or diabetes and have no genetic history of breast cancer, if you are physically active, not obese, and do not have varicose veins, then you do not need to worry. In general, however, women in late 30s and 40s and on the pill should consult their doctor frequently, primarily to exclude the above risk factors.
6. From among the three - long acting contraceptives - IUCD, implant and injectible, which one is the most reliable?
Implants are probably No. 1, but hormonal IUCD is a close second. I would not include DMPA injection in the long acting method as needs to be repeated every two to three months.
7. How soon can I get pregnant after getting an IUCD or an implant removed?
8. I'm a cancer survivor, can I use any of the LARCs?
Yes, if cancer is not hormone sensitive which means not in the reproductive organs then all LARCs can be opted after medical evaluation.
9. Can a woman with diabetes use LARCs?
Yes. Both implant and IUCD can be given to diabetic with special aseptic measures.
A rapid fire round with Dr. Azra Ahsan, consultant obstetrician and gynecologist on IUCD
1. Is it safe?
Yes very safe
2. Does it hurt?
Some discomfort during insertion, none later.
3. Can my partner feel it during sex?
No not at all.
4. Will it interfere with my ability to get pregnant again?
Once removed the fertility is instantly restored
5. How long do I have to wait after giving birth to get an IUCD?
Best if inserted within 10 minutes of childbirth, if not possible then before 48 hours. It can be inserted anytime after 4-6 weeks of childbirth if not inserted within 48 hours.
6. Is it hard to remove?
Removal is a simple procedure, which can be done in a clinic setting.
7. Is there an alternative?
Yes the other possible alternative for a long acting reversible contraceptive is hormonal implant.
To read more about family planning and the situation in Sindh click on the tabs below.
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