The writer is a consultant obstetrician and gynaecologist based in Karachi
Nearly one in every four births is unplanned in Pakistan, while 25 per cent of married women have an unmet need of family planning. This unmet need is reflected in the large number of abortions (890,000 per year) and women hospitalised with complications every year.
Pakistani women are having more children than they actually want, especially in the rural areas. Though cheap and even free contraceptives are available, they are not reaching the user. The methods with the lowest failure rates like the combined oral contraceptive pills, implants and injections and intrauterine contraceptive devices are used by only two per cent of the women. Our contraceptive prevalence rate stands at 35 per cent — virtually unchanged over the last decade. It is dismally low compared to other Muslim countries, which puts to question the faith-based arguments against such devices. Iran has a rate of 73 per cent, Turkey 73 per cent, Morocco 63 per cent, Indonesia 61 per cent, Egypt 60 per cent and Bangladesh 61 per cent.
We are projected to be the fourth most populated country in the world if we continue to reproduce at the current rates. What will our children inherit from us? What can we do about this situation?
For starters, pre-marital counselling should be made compulsory by the government for all couples prior to nikah. This is particularly important because there is no formal reproductive health education in our schools and colleges. Such education should be made compulsory by the government.
Contraception counselling, to prevent unplanned pregnancy, should be combined with health advice and screening: checking of blood groups (to prevent Rhesus incompatability), rubella status (to prevent rubella in pregnancy), thallasaemia screening and the human papillomavirus vaccination (to prevent cervical cancer). Similar measures have already been implemented in Iran with success.
Health professionals also need to focus on women during pregnancy and after childbirth for contraceptive counselling, when women are the most receptive to advice. Once they go home after delivery, they often do not return for follow-ups and hence miss the opportunity for effective family planning. This missed opportunity to prevent unplanned pregnancy can be rectified by proper guidance and perhaps, the insertion of an intra-uterine device in the mother immediately after the delivery so that the necessary preventive measure has been taken care of before she is discharged. Due to cultural reservations and fear of divorce, Pakistani women are often unwilling to opt for permanent sterilisation even when undergoing complicated, life-threatening pregnancies, leading to regular Caesarean sections. Intra-Caesarean insertion offers a very effective and a safe alternative to tubal ligation for such women, providing reversible contraception for up to 12 years, if so desired. Skilled birth attendants and obstetricians need to be trained in the new technique of insertion.
Initial reports of follow-up from a pilot study from two large tertiary care government hospitals in Karachi are very encouraging, showing very low expulsion rates, and ready acceptance by Pakistani women.
Had we followed our own five-year development plan and family planning programmes in the 1950s to 1960s, information regarding the use of contraceptives would have been made compulsory and available to all citizens in both urban and rural areas. Skills training would have been made accessible to all at minimum expenses and technological advancements of the time would have been incorporated in higher education. If this programme had not been impeded due to various reasons, Pakistan would have achieved a one per cent or less population growth rate and the population today would be less than 100 million (compared to over 190 million). Pakistan would have been able to boast of a secondary school education rate of 100 per cent and a higher education rate of more than 50 per cent among young adults. Moreover, we would have been ahead of South Korea, Thailand, Indonesia and India in respect of economic progress. This is an emergency, we need to act now!
World Contraception Day is observed on September 26.
Published in The Express Tribune, September 29th, 2014.
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