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.

“It's really difficult to convince husbands to give consent and sometimes we have to do it multiple times. It can be quite tiresome” - Maria Irfan

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.

Myths come in the way of contraception

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.

The exploding population

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."

Long-acting reversible contraceptives (LARC) are methods of birth control that provide effective contraception for an extended period without requiring user action. They include injections, intrauterine devices (IUDs) and subdermal contraceptive implants.

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.

LARC 20 times more effective than the pill

"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 pregnancies and poverty

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.

A Population Council report noted that in 2012, there were approximately nine million pregnancies in Pakistan, of which 4.2 million were unintended.

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.

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