Introduction Family planning allows individuals and couples to anticipate and attain their desired number of children and the spacing and timing of their births. It is achieved through use of contraceptive methods and the treatment of involuntary infertility. A womans ability to space and limit her pregnancies has a direct impact on her health and well-being as well as on the outcome of each pregnancy. Family planning is sometimes used as a synonym for the use of birth control. however, it often includes a wide variety of methods, and practices that are not birth control. It is most usually applied to a female-male couple who wish to limit the number of children they have and/or to control the timing of pregnancy (also known as spacing children). Family planning may encompass sterilization, as well as abortion. Family planning services are defined as "educational, comprehensive medical or social activities which enable individuals, including minors, to determine freely the number and spacing of their children and to select the means by which this may be achieved". Health Impact The WHO states about maternal health that: "Maternal health refers to the health of women during pregnancy, childbirth and the postpartum period. While motherhood is often a positive and fulfilling experience, for too many women it is associated with suffering, ill-health and even death." About 99% of maternal deaths occur in developing countries; more than half occur in sub-Saharan Africa and almost one third in South Asia. Both early and late motherhood have increased risks. Young teenagers face a higher risk of complications and death as a result of pregnancy. Waiting until the mother is at least 18 years old before trying to have children improves maternal and child health. [11] Also, if additional children are desired after a child is born; it is healthier for the mother and the child to wait at least 2 years after the previous birth before attempting to conceive (but not more than 5 years). After a miscarriage or abortion, it is healthier to wait at least 6 months. When planning a family, women should be aware that reproductive risks increase with the age of the woman. Like older men, older women have a higher chance of having a child with autism or Down syndrome, the chances of having multiple births increases, which cause further late-pregnancy risks, they have an increased chance of developing gestational diabetes, the need for a Caesarian section is greater, older women's bodies are not as well-suited for delivering a baby. The risk of prolonged labor is higher. Older mothers have a higher risk of a long labor, putting the baby in distress. ` "Family planning benefits the health and well-being of women and families throughout the world. Using contraception can help to avoid unwanted pregnancies and space births; protect against STDs, including HIV/AIDS; and provide other health benefits."
Contraceptive methods According to World Health Organization (WHO) Modern Method Traditional Method Modern methods
Method Description How it works Effectiveness to prevent pregnancy Comments
Combined oral contraceptives (COCs) or the pill Contains two hormones (estrogen and progestogen) Prevents the release of eggs from the ovaries (ovulation) >99% with correct and consistent use Reduces risk of endometrial and ovarian cancer; should not be taken while breastfeeding
92% as commonly used
Progestogen- only pills (POPs) or "the minipill" Contains only progestogen hormone, not estrogen Thickens cervical mucus to block sperm and egg from meeting and prevents 99% with correct and consistent use Can be used while breastfeeding; must be taken at the same time each day
9097% as commonly used
Method Description How it works Effectiveness to prevent pregnancy Comments
ovulation Implants Small, flexible rods or capsules placed under the skin of the upper arm; contains progestogen hormone only Same mechanism as POPs >99% Health-care provider must insert and remove; can be used for 35 years depending on implant; irregular vaginal bleeding common but not harmful
Progestogen only injectables Injected into the muscle every 2 or 3 months, depending on product Same mechanism as POPs >99% with correct and consistent use Delayed return to fertility (14 months) after use; irregular vaginal bleeding common, but not harmful
97% as commonly used
Monthly injectable or combined injectable contraceptives (CIC) Injected monthly into the muscle, contains estrogen and progestogen Same mechanism as COCs >99% with correct and consistent use Irregular vaginal bleeding common, but not harmful
97% as commonly used
Intrauterine device (IUD): copper containing Small flexible plastic device containing copper sleeves or wire that is inserted into the uterus Copper component damages sperm and prevents it from meeting the egg >99% Longer and heavier periods during first months of use are common but not harmful; can also be used as emergency contraception
Intrauterine device (IUD) levonorgestrel A T-shaped plastic device inserted into the uterus that steadily releases small amounts of levonorgestrel Suppresses the growth of the lining of uterus (endometrium) >99% Reduces menstrual cramps and symptoms of endometriosis; amenorrhea (no menstrual bleeding) in a
Method Description How it works Effectiveness to prevent pregnancy Comments
each day group of users Male condoms Sheaths or coverings that fit over a man's erect penis Forms a barrier to prevent sperm and egg from meeting 98% with correct and consistent use Also protects against sexually transmitted infections, including HIV
85% as commonly used
Female condoms Sheaths, or linings, that fit loosely inside a woman's vagina, made of thin, transparent, soft plastic film Forms a barrier to prevent sperm and egg from meeting 90% with correct and consistent use Also protects against sexually transmitted infections, including HIV
79% as commonly used
Male sterilization (vasectomy) Permanent contraception to block or cut the vas deferens tubes that carry sperm from the testicles Keeps sperm out of ejaculated semen >99% after 3 months semen evaluation 3 months delay in taking effect while stored sperm is still present; does not affect male sexual performance; voluntary and informed choice is essential
9798% with no semen evaluation
Female sterilization (tubal ligation) Permanent contraception to block or cut the fallopian tubes Eggs are blocked from meeting sperm >99% Voluntary and informed choice is essential
Lactational amenorrhea method (LAM) Temporary contraception for new mothers whose monthly bleeding has not returned; requires exclusive breastfeeding day and night of an infant less than 6 months old Prevents the release of eggs from the ovaries (ovulation) 99% with correct and consistent use A temporary family planning method based on the natural effect of breastfeeding on fertility
98% as commonly used
Emergency Progestogen-only Prevents Reduces risk Does not disrupt
Method Description How it works Effectiveness to prevent pregnancy Comments
contraception (levonorgestrel 1.5 mg) pills taken to prevent pregnancy up to 5 days after unprotected sex ovulation of pregnancy by 6090% an already existing pregnancy
Traditional methods
Method Description How it works Effectiveness to prevent pregnancy Comments
Withdrawal (coitus interruptus) Man withdraws his penis from his partner's vagina, and ejaculates outside the vagina, keeping semen away from her external genitalia Tries to keep sperm out of the woman's body, preventing fertilization 96% with correct and consistent use One of the least effective methods, because proper timing of withdrawal is often difficult to determine
73% as commonly used
Fertility awareness methods (natural family planning or periodic abstinence) Calendar-based methods: monitoring fertile days in menstrual cycle; symptom- based methods: monitoring cervical mucus and body temperature The couple prevents pregnancy by avoiding unprotected vaginal sex during most fertile days, usually by abstaining or by using condoms 95-97% with correct and consistent use Can be used to identify fertile days by both women who want to become pregnant and women who want to avoid pregnancy. Correct, consistent use requires partner cooperation.
75% as commonly used
Family Planning In Pakistan
Even though there is considerable demand for family planning in Pakistan, adoption has been hampered by government neglect, lack of services and misconceptions. Demographics play a large role in Pakistan's development and security since the recent change from military rule to civilian leadership. Challenges to Pakistani's well-being, opportunities for education and employment, and access to health are escalated due to the country's continuously-growing population. It was estimated in 2005 that Pakistan's population totaled 151 million; a number which grows 1.9 percent annually, equaling a 2.9 million population growth per year. Though Pakistan's fertility rates still exceed those of neighboring South Asian countries with a total fertility rate at 4.1 (3.3 children in urban settings and 4.5 children in rural areas) and contraception use is lower than 35 percent, approximately one-fourth of Pakistani women wish to either delay the birth of their next child or end childbearing altogether.
According to Dr. Ansar Ali Khan, an advisor of reproductive health to the United Nations Population Fund in Pakistan, "A combination of factors like non-availability of services, baseless traditional beliefs and misconception play a big role." In addition, Ali Khan stated that "a fairly large number of the population believes the use of artificial contraceptives for family planning is against nature and also against Islam." ] Unlike Family Planning in Iran, a neighboring Islamic republic, Pakistan's family planning program has failed in recent years due to neglect and constant policy changes as a result of political upheaval. While 96 percent of married women were reported to know about at least one method of contraception, only half of them had ever used it.
History in Pakistan In 1950, Pakistan's population reached 37 million people, making it the world's 13th most populous country. [1] Though Pakistan was one of the first Asian countries to begin a family planning program with some help from international donors, fertility has declined slower than in neighboring countries. In 2007, Pakistan had increased in world population ranking to 6th, with over 164 million people and the United Nations (UN) has projected that in 2050 it will move into 5th place with around 292 million people. Muslim populations are incredibly diverse, varying by race, language, and degree of religious conservatism. Some populations are part of countries run by Islamic law, while others live under secular governments. In Pakistan, extremely conservative Islamic beliefs predominate in many parts of the country, in which purdah restricts women to their homes unless chaperoned by a male relative. Additionally, levels of schooling are very low in Pakistan, allowing men to have more power in decision-making. When Ayub Khan was overthrown in 1969, religious demonstrators attempted to discredit the leader morally using the slogan "Family planning, for those who want free sex." This ideology is still present in Pakistan, as the organized religious party opposes family planning because it is "un-Islamic". Though Pakistani couples commonly site religious regions for avoiding birth control, there is not one definitive agreement about family planning and contraception in Islam. In Pakistan, many local religious figures are supportive of family planning and have begun discussions in their communities in order to promote the health of women and children. Although many public health specialists feel that religion plays a major role in resistance to the use of FP in Pakistan, the Pakistan Demographic and Health Survey of 2006-7 showed that religious reasons accounted for only 9% of FP non-use. In fact many NGOs have implemented interventions where they have worked with local or national clergy. Research and Development Solutions (www.resdev.org) reports that there is no quantitative evidence that any of these interventions have resulted in an increase in CPR in these communities.
Current Contraceptive Use in Pakistan Historical political strife and cultural restrictions on women constraining their empowerment have hampered implementation of family planning strategies throughout the country. Most women who say they do not want any more children or would like to wait a period of time before their next pregnancy do not have the contraceptive resources available to them in order to do so. One-fourth of married women are estimated to have an unmet need. In the 1990s, women increasingly reported to wanting fewer children, and 24 percent of recent births were reported to be unwanted or mistimed. The rate of unwanted pregnancies is higher for women living in poor or rural environments; this is especially important since two-thirds of women live in rural areas. While only 22 percent of pregnant married women report to be currently using a modern method of birth control and 8 percent reported to be using a traditional method, lack of widespread contraceptive use could be due to the lack breadth of the current family planning program. The most commonly reported reasons for married women electing not to use family planning methods include the belief that fertility should be determined by God (28 percent); opposition to use by the woman, her husband, others or a perceived religious prohibition (23 percent); infertility (15 percent); and concerns about health, side effects or the cost of family planning (12 percent). Private sector plays an important role in the provision of care of patients undergoing abortions, as more than 60 per cent of all cases were treated by private sector providers. Due to some legal restrictions and the lack of clarity among women and healthcare providers in interpreting the law, women may be forced to seek abortion by untrained providers. Approximately 700,000 women in Pakistan need treatment annually for complications of induced or spontaneous abortion as a result. Extending beyond the reach of family planning and contraceptive methods is the issue of women's sexual and reproductive health. According to the Organization and Population Action International, as of 2007, "only 16 percent of women receive at least four antenatal care visits during pregnancy, less than one-third of births are attended by skilled health personnel, and the maternal mortality ratio, at 320 maternal deaths per 100,000 live births, remains high."
Case studies
Case#1 Couple Name: Zainab and Hussain Age: 27 Years Married: 9 years Blood Group: AB+ Location: Peshawar Rural Area Children: 5 Risk Factor: High Awareness about Family Planning: No General Attitude: Religious approach about Family Planning as sin. Education: Illiterate Contraceptive Used: Pills Used Zainab lives in rural area in joint family system with her husband and 8 children. As Maternal Mortality in year 2010 was 260 as per 1 lakh in Pakistan On one of these visits, Zainab approached the team and they counseled her on a range of modern family planning methods, including condoms, the pill and long-acting and permanent methods. With this knowledge, she made a life-changing decision and chose pills method. Couple Name: Rehmat Bibi and Sikandar Age: 36 Years Married: 18 years Blood Group: B+ Location: Peshawar Rural Area Children: 8 Risk Factor: High Awareness about Family Planning: No General Attitude: Not aware of Family Planning Education: Illiterate Contraceptive Used: No
Rehmat bibi lives in Peshawar rural area with her husband and eight children. The rate of unwanted pregnancies is higher for women living in poor or rural environments; this is especially important since two-thirds of women live in rural areas. While only 22 percent of pregnant married women report to be currently using a modern method of birth control and 8 percent reported to be using a traditional method, lack of widespread contraceptive use could be due to the lack breadth of the current family planning program. They're proud of their large family. Large families are common, but the risks are high. One in eight women in rural areas dies during pregnancy and childbirth. On one of these visits, Rehmat Bibi approached the team and they counseled her on a range of modern family planning methods, including condoms, the pill and long-acting and permanent methods. With this knowledge, she made a life-changing decision and chose a tubal ligation The procedure took just 25 minutes and was performed under a local anesthetic. After the procedure, she appeared fine and satisfied.
Rehmat bibi is one of the lucky ones. Millions of women still do not have access to modern contraception and continue to die unnecessarily as a result of pregnancy and childbirth.
Couple Name: Shazia and Sultan Khan Age: 29 Years Married: 5 years Blood Group: AB+ Class: Upper Class Location: Peshawar City Children: 2 Risk Factor: No Awareness about Family Planning: Yes General Attitude: Positive approach toward family planning Education: Literate Contraceptive Used: Yes Pills and Condoms (Traditional Method) Now using IUD (Intra Uterine Device for five years)
Couple Name: Mehwish and Mansoor Age: 32 Years Married: 7 years Blood Group: A+ Class: Upper Class Location: Peshawar Children: 2 Risk Factor: No Awareness about Family Planning: Yes Contraceptive Used: used Condom and family planning pills before but now using Norplant Norplant (chances of NOT getting pregnant): More than 99%) Six capsules containing synthetic hormones inserted under the skin of your upper arm. Capsules slowly release hormones into the bloodstream over a 5-year period. These hormones stop the ovaries from releasing an egg each month. Hormones also thicken mucus in the cervix (opening to the uterus), stopping sperm from entering it. Reversible method of birth control. It is expensive method available in foreign countries. Note that Couple applied this method in Ireland.