Neelam Bibi* is working as a nurse in a far-flung area of Balochistan, shahkarez village, to provide maternal care services to women who are less aware of Modern Family Planning (FP) methods. Today, she rushed to the civil hospital Quetta with a close family member to treat an unexpected pregnancy-related issue. The condition of the mother is serious due to her 11th pregnancy and could not be treated in the district hospital, Loralai.
As per the definition of WHO, FP is the ability to limit the number of offspring along with anticipating the timing and spacing of births. Above all, it is achieved via contraceptive methods and the handling of involuntary infertility. Equally important, the FP services include planning birth spacing, avoiding unintended pregnancies, and lessening the number of abortions, which lie in the category of better provision of contraceptive facilities. Moreover, pregnant mothers need counseling along with those spouses who wish to conceive and need infertility treatments.
In the words of Neelam;
“Here, in Balochistan, women have limited financial independence. Besides, women cannot move freely owing to gender stereotypes and cultural practices. Consequently, many women who even endorse the effectiveness of family planning and modern use of contraceptives remain unable to access it.”
Unfortunately, women in rural areas could not use contraceptives despite wishing for birth spacing. In this regard, different research studies such as “A Gendered-Based Assessment of Utilization of Primary Health Care Services and Associated Factors in Pakistan”, 2020, have reported that Primary Health Care Services (PHCs) are still underutilized due to the stigma associated with the concept of family planning. On the other side, women in urban areas are active in adopting FP services that even put contraceptives out of stock in many cases. However, large portions of Pakistani women still have an unmet need for modern FP methods as indicated in a study titled “Population, Fertility, and Family Planning in Pakistan: A Program in Stagnation” by K. Hardee and E. Leahy.
Despite investments and funding, FP services are not availed at the desired rate. As far as Balochistan is concerned, little has been done to gauge the contraceptive prevalence rate, particularly in the rural-cum-conservative areas where males desire more and more kids. In one of the studies, it is stated that Balochistan has the highest rate where women have unmet needs for FP services as compared to Punjab and Kp. Similarly, another study titled “Improving Design and Delivery of Family Planning Services To Meet The Unmet Need For Contraception In Quetta Balochistan”, 2018, has indicated that even in the provincial capital, Quetta, 76% of married women want to adopt FP methods but only 33.8% can access the facilities.
Following that, Dr. Paras Shehzad, neonatologist at Naggi Hospital, Quetta, remarked that women in conservative cultures have no power for independent decision making whether it is access to FP methods or maternal/neonatal health care. Besides, he also maintained that the health structure is itself deficient in dealing with the issue of recurrent stock-outs of contraceptives along with training and resource allocation for health workers who serve in the hard areas of the province.
He further continued;
“When health workers are not properly trained and there are not enough resources for the overall health infrastructure, this, in turn, demotivates women to either consul or adopt modern FP methods.”
Following that, Dr. Bari, child specialist at Quetta, also lamented the fact that maternal and child health is not associated with the family planning initiatives creating a loophole in the healthcare system that not only fails the initiates but produces incoherency at the policy coordination level as well. However, he also acknowledged that in-laws and husbands disapprove of FP methods alongside the fear in society that speaks of the side effects of contraceptives at the later stages of life.
Moreover, Abida Bibi*, LHV at Loralai Civil Hospital, was asked to describe the associated myths and beliefs regarding contraceptive methods. According to her, many people still think negatively of the modern FP methods including injections, implants, intrauterine contraceptive devices, and pills. However, she agreed with the fact that these myths are sociocultural concoctions. These myths include weight gain, menstruation problems, stomach aches, and most importantly infertility.
Abida Bibi* further continued;
“Many women come to me and tell me what their in-laws or relatives think of the FP methods. Few think these methods will affect their uterus and they will not be able to bear pregnancy. In the same vein, some have even expressed fear of loss of blood in their body as well.”
In a research paper titled, “Improving Design and Delivery of Family Planning Services to Meet the Unmet Need for Contraception in Quetta Balochistan”, 2019, it is stated that 76% of the respondents surveyed favor using FP methods but 33.8% could do so. Owing to the reasons, it is also described that the majority of the participants did not adopt the FP method due to perceived side effects of contraceptive methods. In addition, a non-supportive husband and the out-of-stock services as well.
It is pertinent to mention that men also upheld the myths surrounding the use of contraceptives. Muhammad Usman*, working as a shopkeeper in Quetta, mentioned that contraceptives can physically harm her wife and that’s why he does not allow his wife to use them. Unfortunately, the level of counseling men at the community level about the effectiveness of family planning is almost nonexistent in Balochistan. Despite these harsh circumstances, health workers try hard to convince in-laws or husbands to go for the process.
In the words of Abida;
“Many men speak fowl of LHVs when we introduce the concept of contraceptives. Some even scold their wives and forbid them to visit us again. Socially, it is considered unethical and irreligious as well.”
Moving forward, Abdul Rehman, Lecturer Islamiat at Loralai district, was asked to narrate the religious perspective about family planning to unravel the stigmas associated with FP methods. According to him, religion encourages birth spacing which is essential for maternal and child health care. In addition to that, he lamented that people have less knowledge about the religious injunctions that allow birth spacing. However, it is just a wild myth that birth spacing or the use of FP methods are sin.
He also remarked;
“We are increasingly becoming conservative rather than religious when it comes to family matters.”
Sadia Jabbar, a teacher at Loralai, also highlighted the fact that religion empowers women and allows them to be equal decision-makers at home and in society. They have their reproductive rights and freedom to go for the pregnancy after birth spacing. She also said that it is her firm belief that husband and wife should go for joint- decision-making when it comes to any matter of family especially the use of contraceptives.
Jabbar further states;
“Husband and wife together bends the course of family planning and religion allows to do so. It is another thing that society does not allow to have healthy planning at all. In a nutshell, we have to fight this social pressure and stigmas that have impacted maternal health adversely.”
In contrast, if we look into the households, on average every spouse has more than 7 kids. Dr. Faryal Khan, LMO at Kacchi District, mentioned that the want of a son causes families to have more and more kids until and unless they don’t get a son. Amina Ahmed*, a resident of the Pishin district, is one such wife who has fifteen daughters and still wants to go for the sixteenth pregnancy hoping she will rear a son.
In her words;
“It is my utmost desire to have male kids because boys are the symbol of power within the family. If I do not have a son my position in society would even be stigmatized for being not a mother of a son. Besides, my husband may also get a second or third wife if I don’t give birth to a son.”
Unfortunately, Amina Ahmed is one such lady who has been stigmatized for having daughters and not sons. In addition to that, tribal societies also go for more kids to generate income as young boys do daily labor and girls go for knitting/weaving to generate income for the family.
In a nutshell, FP services in rural areas go unutilized due to stigmas associated with them. These myths include social, religious, and even false scientific explanations to avoid birth spacing and limiting the desired number of offspring. However, it is also witnessed that women in rural areas wish to adopt these services but cannot do so due to male dominant social structure that is based on the want of sons or more and more kids.
Tahira Khan :
A freelance journalist from Loralai district, Balochistan. Can be reached at [email protected]