Over two decades into the practice, Dr Azra Ahsan has noticed that many couples, who come seeking obstetric or gynaecological advice, are uncomfortable about telling the exact number of children they have.

When she inquires, it is usually the father who replies, often giving a range and never a definite number. "It is either four or five, six or seven, 11 or 12,” says Azra, who is also technical consultant at the Ministry of Health’s National Committee for Maternal & Neonatal Health (NCMNH). She remarks that “the actual number is normally higher and they are too embarrassed to tell”.

Fathers are sometimes unable to remember their children's name or recall them in a chronological order. "I do not think that men think about the consequences of having unprotected sex. They have it because they have nothing better to do and babies are just a side effect of it," she observes.

Dismal overall

While Pakistan has not had a census since 1998, the estimated population of the country is 193 million according to the United Nations (UN), making it the sixth most populous country in the world. According to Population Reference Bureau, by 2050, Pakistan will climb to fifth on the list, given its population growth rate.

But it seems that the country’s political leaders have yet to comprehend the gravity of the situation. "I have never heard the prime minister or the opposition leaders say that soaring population is a critical issue and that family planning (FP) is a solution," says Dr Farid Midhet, a demographer at the John Hopkins University, affiliated NGO Jhpiego.

"The common man's health, especially women's health, is just not on the government's radar," concedes FP expert Dr Aleya Ali. "We're way behind our target of providing modern contraception methods to 55% of the couples," she points out.

According to the Pakistan Bureau of Statistics, the country's FP score declined by 7.2% in the year 2014-15 compared to the previous year. The score is calculated on the basis of contraceptives sold or distributed free of charge during a period of one year. The score dropped the highest in Punjab (13.4%), followed by Sindh (2.2%), Khyber Pakhtunkhwa (1.2%), and Balochistan (1.3%).

Poor performance or shortage of staff, unavailability of contraceptives and low clientage were to blame for the poor performance in the provinces.

State ineptitude

The responsibility to promote FP comes under the Family Welfare Centres (FWC), but like most government departments, the FWC is underperforming. Dr Aleya points out that that the FWCs work like "government offices from 9am to 2pm and are unable to serve those who may want to come after work".

The Jinnah Postgraduate Medical Centre (JPMC) FWC in Karachi has an 18-member staff, yet they do not make the effort to reach out to their clientele. Dr Azra says that “if they would walk up to the immunisation clinic and the gynecologicals ward within the JPMC premises and counsel the scores of women waiting there, it can make a huge difference".

Some FWCs exist only on paper. In Sindh, for example, there are over 800 FWCs, but most are non-functional, according to Dr Farid.

The FWCs that do receive those seeking assistance, the quality of the counseling is not up to the mark. “It amazes me that my own colleagues are often skeptical of contraceptives for fear of side effects. If they are not completely convinced themselves, how can they advise their patients?” wonders Dr Azra.

Dr Ahsan adds that "there is no proper counselling to prepare women in advance for the minor discomfort they may face at the start of a hormone-based contraceptive method and how to deal with it." The consequence is that women often stop using contraceptives as soon as they experience discomfort. It may also result in women in entire neighbourhoods or villages looking at contraceptives with wariness.

Targeted improvement

However, not everything is dismal. The government is now trying to target the 48% of women who deliver in health facilities and leave without receiving counseling or any family planning services. Majority of these women do not return for postpartum check and often come back with unintended pregnancies.

The program started four years ago and among the contraceptive methods being promoted are implants and intrauterine device (IUD).

“While implants are fairly new in Pakistan, IUDs are not. Implants and IUCDs are categorised as long-acting reversible contraceptives (LARCs); they are safe, long lasting, and discrete. An IUD can last for up to 12 years," informs Dr Ahsan.

"Unlike sterlisation, women can get the device or the implant removed the moment she decides to conceive," Dr Ahsan adds.

23 hospitals in total in Karachi, Lahore, and Islamabad have the skilled staff to provide IUDs. 31, 639 women have consented to this method of contraception over the period of time.

"Antenatal care has increased over the years in Pakistan; more women are now frequenting health facilities for deliveries than they did 20 years back when home births were more common. So health practitioners have this small window of opportunity to provide services," Dr Ahsan says.

"It's the only way to make some headway," says Dr Aleya, who also favours these methods of birth control. "The setting is perfect: the woman is present, the skilled birth attendant is there, as is the contraceptive. The woman just has to give her consent," she adds.

While it is still too early to say what their preferred choice would be, Dr Azra finds that women are becoming accepting of implants as they are not inserted into the uterus, making women less fearful.

But general awareness, as well as affordability, is still the main issue. The implant may cost Rs800 with Rs1,000 as service charges. Many can’t bear this onetime cost. "They spend money on cigarettes daily but refuse to pay for contraceptives," says an irate Dr Azra.

Header photo by author

The writer is a freelance journalist. She tweets @Zofeen28