Family Planning: Back to Basics
It does not seem so long ago when the women’s health movement marked a major victory in Cairo, as the United Nations Conference on Population and Development 1994 voted in favor of a broad-based reproductive health and development agenda to replace the narrow demographic-based obsession with using family planning to curb population growth rates.
Countries were exhorted to widen their population control programmes to incorporate agendas such as sexual health and rights, poverty and health, and reproductive health needs of women across their life-cycles not only those years devoted to child-bearing.
Benazir Bhutto, who was Prime Minister at the time, attended the Cairo conference and delivered an excellent speech in support of the new agenda. Pakistan worked as a moderate Muslim country negotiating with countries such as Saudi Arabia and Iran to win their support for the Conference Programme/Platform of Action. Donor funding for Pakistan became available for government and non-government organizations alike to work on a variety of new areas, such as HIV/AIDS and other sexually transmitted diseases.
Now 17 years later, there is plenty of new information that has come to light that gives us pause to think and assess how far we have come. One such source of information is a recent study conducted by the Collective for Social Science Research on induced abortion in Pakistan. Interviews were held with 477 women distributed across 28 communities (mainly in Punjab and Sindh) who had induced abortions during the preceding five years. They answered a variety of questions exploring their entire pregnancy histories, related health-seeking behavior, and the reasons for and details of their induced abortions.
The women with induced abortions could be divided into two groups: the first (88 percent) included all women who did not wish to become pregnant but nonetheless conceived, and the second (12 percent) comprised of those who decide after conception against keeping the pregnancy. The first group comprised of women who were either not using contraception or who had experienced contraceptive failure/misuse and had therefore had an unwanted pregnancy.
Another section of the survey focused on women being treated for post-abortion complications in a government district hospital in Karachi. They numbered 117 respondents over a one-month period, and the cases represented all types of pregnancy loss: spontaneous (eg miscarriages), induced (voluntary) and induced (for medical reasons). During the period they were in hospital (which ranged from a matter of hours to two days), some were referred for post-abortion family planning services to a government outlet on the hospital premises, but a full 56% were not given any counseling at all. Only twenty patients were counseled about family planning and its benefits, and 18 were sent to specific providers of contraceptive services.
Immediately following a pregnancy loss is the critical time for a woman to receive counseling on how best to plan for future pregnancies. If women leave a hospital without such information or without contraceptives in hand, an opportunity is lost to equip them with the resources needed to space or limit childbearing. Since it is a major achievement for women to come to hospitals in the first place to receive pregnancy-related treatment, doctors and nurses alike
need to take full advantage of their brief interaction with patients.
This is not as easy as it sounds. Anyone who has spent a bit of time in the gynecology or labour wards of Karachi hospitals knows how large the caseload is on a given day. According to the administration department at one of the largest government hospitals in Karachi, the outpatient caseload is between 2,500 to 3,000 patients per day, and more than 1000 patients admitted daily. At the obstetrics and gynecology departments at the hospital, 20 to 25 deliveries are administered every day and the daily outpatient caseload is close to 200 patients. Doctors have reported they generally don’t have time to counsel patients and even when a patient is referred to the family planning centre, which is within the hospital compound, there is no way to ensure the patient will follow this instruction. There are no waiting areas for women or their attendants and they usually have wait in hallways.
At a district level hospital in Karachi there may be as many as 9,000 women seen in the Out-Patient Department in a one-month period, and 500 obstetrics patients admitted, along with over a hundred gynecology cases. Staff is rushed and over-worked, and midwives or nurses may fill in for procedures that doctors are officially supposed to do – such as the evacuation of a woman’s uterus after a post-abortion complication.
There are government family-planning centres in public hospitals, to which women are meant to be referred from out-patient clinics or by staff attending to admitted patients. But these are not always friendly and hospitable environments, sometimes only accessible to a woman after she waits in yet another endless queue, and sometimes so over-flowing with women needing advice and understaffed with service providers, that a patient will postpone the consultation and return home instead.
This turns out to be a costly mistake. The Collective research on induced abortion calculated the costs of this and the other alternatives to it: that is, spontaneous abortion or a pregnancy taken to term (delivery). Even including the expected cost of treating a complication, the out of pocket cost of an induced abortion was Rs. 4,600, a spontaneous abortion Rs 3,062, and a delivery Rs. 7,273. In short, this makes having an induced abortion, with its risks, far cheaper than a delivery. And when these costs are compared to the out-of-pocket expenses of using contraception, the contrast is even more stark: one year on the oral pill costs less than Rs 200, and a tubal ligation (which is permanent) costs Rs 1,000. The numbers alone are an excellent reason for fixing our family planning services in Pakistan and making them accessible, user friendly, and widespread.