How Pakistan can use Larc to manage the public's family planning needs

Pakistan's birth rate stands at a whopping 3.6, a marginal decline from 3.8 in 2012-13.

Updated 11 Jul, 2020 01:21pm

When the prime minister began urging Pakistanis to watch the Turkish historical TV drama Dirilis Ertugrul (Ertugrul's Resurrection), also described as the Muslim Game of Thrones, his reasons may have purely been to glorify the Muslim value system, the Ottomon Empire, and to counter Islamophobia.

But now that Pakistanis have got a glimpse into what Turkey's glorious past may have been like, it may be the right time to introduce them to present day modern Turkey, even emulate and aspire to be like them in some areas.

For instance, one thing that Pakistan can learn from is how to keep its population manageable.

Just ahead of this World Population Day, the Turkish Statistical Institute has released data to show that the country's fertility rate (the number of babies born to a woman during her reproductive cycle of ages between 15 and 49) has dropped to 1.88 from 2.38 in 2001, which is even lower than the standard replacement (when a generation replaces itself from one generation to the next) level of 2.1. On the other hand, Pakistan's stands at a whopping 3.6 births per woman according to the latest Pakistan Demographic and Health Survey (PDHS) 2017-18, a marginal decline from 3.8 in 2012-13.

Urbanisation, women pursuing education and their active participation in the workforce are some of the reasons Turkish experts attribute to women postponing childbirth and the reason for the slowdown in the fertility rate.

In Pakistan, although women constitute 49% of Pakistan's population, only 24% are counted in the labour force. By age 49, on an average, a Pakistani woman gives birth to more than five children, and many births are not spaced. The average birth interval is two-and-a-half years, although 37% of births still occur within 24 months of the last birth. Teenage pregnancy is rife and it is highest among girls with no education. According to the United Nations Population Fund, only 10% percent of married adolescents aged 15-19 access family planning (FP) "due to the negative attitudes from health providers and lack of targeted, youth-friendly interventions".

A population multiplying exponentially and the need for family planning

It is only after giving birth to four kids that a woman wants to limit further pregnancies. And so, if most couples want four children, convincing them to use family planning before they reach their target may be an uphill task for the state that wants to get a handle on the population bomb and is keen on promoting the long acting reversible contraceptive (Larc) which are not only long-lasting and reversible but also safe.

There are two such methods — implants and intrauterine contraceptive devices (IUCDs), although some experts also includes injectibles (which last for three months) in Larc.

Daily wage earner Liaquat is happy with his brood of four. Married for seven years and never using a contraceptive he and his wife Sapna have four children — two daughters and two sons (aged four years, three years, and two years, with a fourth one just five months old).

"My family is complete," he says, adding that their last baby would have been their fifth had their first born, not died soon after birth. He had not worked out exactly how he was going to feed so many mouths with the paltry Rs 1,500 per day that he earned, but was not overly worried.

It was during the antenatal before the last birth that Sapna's doctor convinced them to get an IUCD inserted into her uterus while she was still on the delivery table.

With more and more women delivering at hospitals (the latest PDHS says it is 66%) it perhaps gives healthcare providers that perfect but small window of opportunity to promote this method.

Sapna and Liaquat may wish to have four children but health experts fear that if couples continue to have unplanned babies, and so many of them, Pakistan's population will double from 207 million to 440 million by 2055.

And if Pakistan's population continues to grow at the current rate of 2.3% annually and the economy fails to keep pace with it, that will spread country's resources too thin. This may mean longer power outages, more kids out of school, and more malnourished children.

"No one seems committed to resolve the issue," says Dr Azra Ahsan, gynecologist and obstetrician with over two decades of experience.

Why are not enough women interested?

When asked about her position on Larc, Dr Ahsan, who is president of the non-profit Aman (Association for Mothers & Newborns), found it to be a sure shot way of tackling Pakistan's runaway population. The woman will be stress-free for as long as 12 years in the case of an IUCD and for five years with an implant."

But fewer women seem interested.

Dr Ahsan blames both governments which every now and then make some noise but "fail to take any concrete action" as well as people from her own fraternity — the health care providers (HCPs) "who do not think an exploding population is an issue or that counseling and providing family planning is their responsibility".

Dr Yasmeen Qazi, senior advocacy consultant to the Bill and Melinda Gates Foundation, added that "a weak governance of the FP programme managed by two vertical ministries of health and population" in provinces was failing to reach women and couples in need of FP.

Explaining how the FP programme was being affected by the two ministries, Dr Qazi said that health ministries were not interested in FP since it has not been their mandate traditionally though they have larger and stronger health teams and providers. She added that the population ministries, on the other hand, are fully focused on FP but are small in size and do not have either the capacity or the budgets to handle the issue.

She adds that Sindh was the only province where health and population had one secretary reporting directly to Minister for Health and Population Welfare Dr Azra Pechuho.

Women and unborn babies are the losers in this skewed scheme of things. "It often results in mistimed and unwanted pregnancies with high abortion rates," says Dr Qazi, to which Dr Ahsan adds: "Almost half of all pregnancies in Pakistan are unintended and the couples just resort to abortion instead of planning their family."

Dr Ahsan adds that she counsels women "with their best interest in mind, considering their medical conditions". And then they refuse advice based on their social and cultural considerations and beliefs.

"I feel extremely frustrated," says Dr Ahsan.

Misconceptions surrounding Larc

Mariam Jawad, 34, gave birth to a third son just two weeks back. It was a difficult time since she had tested positive for Covid-19 and had been in quarantine until a few days before giving birth. Her husband was still in quarantine when she went to the hospital for delivery. "I felt very lonely and my doctor had counseled me to get an IUCD inserted since I was in the hospital and for which I, too, quite convinced", but at the last minute she got cold feet and declined.

Part of the reason for her reluctance were side effects that people had told her about, including "weight gain and hormones in your body". In addition, after she heard that "two people got pregnant with the coil", she got even more wary. However, she never cleared up the confusion in her mind with her obstetrician.

Dr Ahsan admits that minor weight gain can happen with hormonal contraceptives but not with IUDs.

But more than patients who don't have a medical education, Dr Ahsan is baffled by doctors who are staunch believers in the plethora of myths and misconceptions that abound around modern methods of contraceptives. "Doctors come to me with questions like: will using contraceptives lead to weight gain, infertility or even cancer?" she says, adding that "family planning is just not taught in medical colleges."

Dr Qazi, has for years been advocating for "addressing and responding to misinformation and confusion about contraceptives' use" to enable positive demand for FP, she says. But then, the government must also ensure an uninterrupted supply of contraceptives that "reaches the last mile" along with high quality of services.

For this to happen, the foolproof strategy Dr Qazi has in mind involves girls and women leading "the change that they want" from and at the grassroots and those sitting in "positions of power to influence positively on laws and policies concerning women's health and rights".

But for now, it is the pandemic, that has stalled many FP programmes across the country. When the government announced a lockdown back in April, it closed FP centres too and women were unable to get FP supplies, or access antenatal or delivery care. For example, the data for People's Primary Healthcare Initiative in Sindh, which manages 1140 primary healthcare facilities of the province on Larc, shows a sharp dip. The number of IUCDs inserted in January and February was 6,240 and 8,997 respectively, but slipped to 4,398 in March. Implants showed a similar trend. In January and February of 2020, the number of implants consumed was 6,036, in February 2020, it was 14,026, and in March 2020, a total of 5,094 implants were used.


Author Image

Zofeen T. Ebrahim is an independent journalist based in Karachi.

She tweets at @zofeen28.

The views expressed by this writer and commenters below do not necessarily reflect the views and policies of the Dawn Media Group.

Comments (13) Closed

Jul 11, 2020 09:17am
The world in general is going to suffer from population collapse in the very near future . The western culture of consumerism and selfishness has permeated the world added to the sin of female infanticide in the two biggest populations. It is good to exercise family planning , without using the pill , but more attention and resources should be given to education and training of young people who will be desperately needed across the globe.
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Jul 11, 2020 09:39am
Its high time that we think outside the box in resolving the issue education is more important , than insanely pressing them for contraceptive and others , masses should be educated to live a better and productive life
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Think twice
Jul 11, 2020 09:54am
A comprehensive policy for population control is required for this poor country with finite resources. Any country quality of life is depends on resource and number of people using it. Unsustainable population growth leads to only one commodity which is cheap. Lives.
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M. Saeed
Jul 11, 2020 10:08am
Nobody would talk about Attaturk outlawed beards and shabby dresses for the prayer-leaders. That was his biggest single contribution in modernising and developing Turkey.
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Aamir Alvi
Jul 11, 2020 12:17pm
Of all the problems that beset Pakistan,population stands out as the one which requires urgent and utmost attention of the government.Economy,despite growth, dwindling water resources,fertile land making way for the housing schemes are all victims of runaway population - need I write more to drive home this point?????
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Shushant Singh
Jul 11, 2020 02:24pm
Way to go
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Chrís Dăń
Jul 11, 2020 02:57pm
A wonderful article. Every woman and specifically every man in Pak8stan needs to read it and to think about it. This article should be published in National as well as all provincial languages also to reach everyone. The most important thing:the article should be firwarded to PM secretariat as well as Islamic Council also. Thank you Dawn,for giving us an opportunity to have this article.
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Jul 11, 2020 03:32pm
Going to a gynae doctor in Pakistan is generally a bad experience. They are only interested in earning money from C-section deliveries. Doctors counselling girls and women on reproductive health and well-being is a rare phenomenon. I specifically asked about FP from a very expensive private practitioner after my first delivery. She was completely dismissive and I ended up having my second pregnancy within 18 months. Took a serious toll on my health. Being from an affluent family I could get the care and support for myself and my children. How many other women can?
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Jul 11, 2020 04:34pm
The most important is in providing a national health care service, targeted especially for women and children , it's all very well talking about reducing the number of children per household, they are meaningless with the level of infant mortality. The provision of nutrition for both mothers and children. Providing medical care for mothers to be, and providing extra nutrition for them, so that both mother and child get the necessary vitamins and supplements, and up to at least for five years a structured health plan for the child. it's all very well espousing western concepts without taking into consideration the needs of the mother from a religious and cultural aspect, it seems there are many in Pakistan who parrot whatever they learn from the west.
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Jul 11, 2020 05:06pm
The most effective tool to control population growth is not contraception. Educating the girl child is the only effective, non-coercive way to population control. Sure, contraception methods should be available. But they can only be opted for by a woman who feels confident about herself. Education also delays the age of marriage, making both the husband and wife more mature and circumspect about life's major events.
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Jul 11, 2020 08:27pm
More population means more competition. Look at India, so over populated and so much competition that students are committing suicide. 30 years ago it was easier to get into a government medical college now so many students apply and hardly any seats.
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Taj Ahmad
Jul 11, 2020 08:34pm
In Pakistan, birth rate is too high in rural areas where 70% people are uneducated compare to big cities where 50% are educated and birth rate are much lower. Pakistan's over all birth rate are still too high compare to India, Bangladesh and Iran. Let's all bring birth rate down in Pakistan one newly married couple maximum two children and minimum one child in their marriage lives.
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Jul 12, 2020 07:48am
@sami, Do mention Japan and South Korea.Suicides do not only arise from population explosion, but also from higher expectations and lack of opportunities for the poor people.
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