S-11

From Contraceptive Prevalence to Family Planning Service Users: Implications

for Policy and Programmes
Adnan Ahmad Khan, MBBS, MS,1 Khadija Abbas, MSc,1 Hasan Bin Hamza, MBBS, MSc,1
Ahmed Bilal, BSc,1 Ayesha Khan, MBBS, MPH1

Abstract Introduction
Introduction: Contraceptive prevalence rate (CPR) is The contraceptive prevalence rate (CPR) is a widely
a widely accepted measure of maternal health and accepted measure of maternal health and women's
uptake of family planning (FP) services. How ever, the empowerment 1 and is used worldwide in different
overall CPR obscures the actual utilization of FP aspects of health policy planning and formulation. 2
services due to over-representation of long-term However, CPR is not the best tool to measure and plan
methods. This study used CPR from 2007 to arrive at family planning (FP) services. In this paper w e
and compare the number of actual number of w omen propose a slightly different method of estimating the
who availed different FP services in order to quantum of FP services from the number of women
understand issues and gaps in FP services in Pakistan. being served annually to help identify the scope of
and gaps in FP services at the national level.
Methods: This study used secondary data from the
Pakistan Demographic and Health Surv ey 2006-7 The CPR — described as the percentage of women of
estimate the CPR and modern method mix for reproductive age (i.e. 15-49 years), or their
2007.These were then multiplied by the estimated spouse/partner, using any contraceptive method at
number of married women of reproductive age any given point in time 3 — in Pakistan is the lowest
(MWRA) to arrive at the actual numbers of women among all its regional neighbours as w ell as some
using specific FP methods and utilizing FP services in other developing countries. 4 The average CPR in
a given year. South Asian countries is around 47% (2000 to 2009). 5
While Pakistan has managed to increase CPR from
Results: In 2007 the CPR was 30% overall and 22% for
4%6,7 to 30% 8 in the 40 years from 1966 to 2006, its
modern methods. However, the number of women
regional neighbours have increased their FP usage
availing FP services decreased to 12% when adjusted
much more substantially. Indeed, current CPR in India
for FP users who had availed services in the past 12
is 54%, 53% in Bangladesh, 79% in Iran 79%, and 57%
months. Within this "service mix", self-procurement of
in Indonesia. 5 Countries that have implemented FP
FP commodities directly from stores without a advice
programmes successfully have demonstrated political
from a health provider constitutes around 37% of all
support for FP reflected that has translated into
FP "services" and the public sector accounts for
effective services and the creation of FP-conducive
another 33%. Condoms are the commonest method
environments. 9-14 Such policies have helped shape
served, accounting for over half of all "services".
favourable public perceptions for FP and
Conclusions: The bulk of FP is self-procured and the communicate the government's will on FP. While
service mixed is skewed towards client controlled Pakistan has done many of the same efforts as its
methods that do not require medical advice. Thus, neighbours, these have been disjointed and
lack of quality for contraceptiv e services that require inconsistent and backed by inadequate planning or
some form of supportive healthcare services and measurement of performance of existing programs 15
counselling may be a bottleneck to improving CPR. that has resulted in dissipation of success of ev en
those programs that had been effective at the
Keywords: Family planning, CPR, Contraception, beginning. 16 If FP programmes are to succeed in
Utilization, Policy, Pakistan, Programming, Service delivery. Pakistan and to meaningfully affect population
growth, policies and programs will hav e to be backed
Research and Development Solutions, Islamabad. consistent support that is informed about
Correspondence: Adnan Ahmad Khan. Email: [email protected] performance, successes and gaps in real time and by

Vol. 63, No. 4 (Suppl. 3), April 2013

S-12 A. A. Khan, K. Abbas, H. B. Hamza, et al.

specific locations. For this to happen, accurate sectors and self procurement from stores. Women who
measure of success and gaps will hav e to be reported receiving their method from friends or
considered. relatives were counted as having self-procured their
method. Current users of modern FP methods were
Pakistan Government devolved health and population
adjusted for methods received within the past 12
from the federal to provincial governments in 2010-
months as above. This included all users of condoms,
11. 17 This brought the management of these programs pills and injections along with 18% w omen with an
one step closer to the grassroots. How ever, this still
IUD and 9% with sterilization. The proportion of
means that provincial authorities must decide about
women by each source of FP was multiplied with
remote health facilities located in provinces that hav e
actual number of services users to estimate the
20-40 districts each and can have up to 96 million
number of women that availed FP services from each
population. This means that these officials must hav e
of these sources.
precise, real time data that can discern service
delivery and uptake patterns at facility lev el. Much of Results
this is in the form of service delivery and commodity Approximately 7 million w omen use some form of
data of the health and population departments. family planning. Among these, 5.3 million use a
However, periodically these data must be triangulated modern contraceptive method, while others use a
with service uptake data from community based traditional method. When modern contraception users
surveys to understand gaps, inefficiencies and issues. were adjusted for women who had availed
This paper proposes one such methodology to use contraceptive services within the past one year, the
existing survey data about FP usage and venues from number of women drops from 5.3 million modern
where services were availed to describe the quantum contraception users to 3 million w omen — around 12%
of services for in depth analysis of service deliv ery of the MWRA — that avail FP services in any given year
patterns. (Table-1). This change alters the method mix in that
condom provision becomes the predominant "service"
Methods accounting for 55% of all FP services followed by pills
This study used data from PDHS 2006-07 to compute and injections; while female sterilization that had
the annual CPR for 2007 and to estimate the number of constituted 38% of the method mix in the CPR only
women who availed FP services in 2007. According to accounts for 6% of all FP services (Table-2).
the Pakistan Bureau of Statistics, there w ere 24 million
MWRA in 2006-07. This is an estimate based on A more pertinent pattern that emerges is that services
extrapolation of the 1998 census data using an annual for long term methods such as male or female
population growth rate of 2.1% (UNFPA 2012). sterilization and IUDs constitute a small proportion of
the "service mix". Only around 0.18 million w omen
The number of MWRA using FP and particular receive female sterilization, 0.1 million receiv e IUDs
methods were calculated from the distribution of and nearly no men receive male sterilization. Thus
women for age groups of 15-19, 20-24, 25-29, 30-34, 35- less than 0.3 million individuals receiv e any long term
39, 40-44 and 45-49. In each of these age groups, we method services in any given year.
multiplied the proportion of users of each method by
Another salient finding is the distribution of services
the total number of women in each group to arriv e at
between the public sector, private doctors, NGOs and
actual number of users of each FP method by age
the number of women who directly buy services from
groups. Total number of users of each method was
stores or chemists/ pharmacies. All told the public
calculated as the sum of all users of that method in
sector serves around one million w omen. The
each age group. Since IUDs and female sterilization
Ministry and Departments of Population Welfare
are multi-year methods, women who had received an
serve 0.47 million women while the Ministry and
IUD or sterilization in the last 12 months w ere added
Departments of Health serve 0.53 million women.
to all users of condoms, pills and injections to arriv e at
Together that accounts for approximately 4% of all
the number of women who avail any FP service in a
MWRA. NGOs and private health provider account
year.
for approximately 16% of the services (2% of MWRA),
The PDHS also asked women about where they had while a staggeringly high 35% of women directly buy
received their FP methods from. These include the FP supplies from stores where they are extremely
several types of facilities in the public and priv ate unlikely to receive any instructions or counselling

J Pak Med Assoc (Suppl. 3)

Vol. 63, No. 4 (Suppl. 3), April 2013

From Contraceptive Prevalence to Family Planning Service Users: Implications for Policy and Programmes
Table-1: Services provided last year (PDHS 2006-07).

Total MWRA with Total MWRA Female sterilizations IUD conducted Pills Injections Condoms Total Modern Total contraception (%)
Female sterilization with IUDs* conducted in 2006-7 2006-7 Method Users services last year
Public Sector 1,477,326 297,464 132,959 54,084 235,678 294,094 283,913 2,600,373 1,000,729 33%

Ministry and Departments of Population Welfare 1,446,718 201,527 130,204 36,641 79,069 162,875 57,459 1,959,701 466,248 15%
Government hospital/RHSC* 1,377,341 156,112 123,961 28,384 66,316 92,660 45,629 1,744,349 356,950 12%
Rural health centre/MCH* centre 48,972 11,354 4,407 2,064 - 23,597 1,690 86,141 31,758 1%
Family welfare centre - 34,061 - 6,193 12,753 46,618 3,380 96,908 68,944 2%
Mobile service camp 20,405 - 1,836 - - - 3,380 26,919 5,216 0%
Male mobilizer - - - - - - 3,380 5,384 3,380 0%
Ministry and Departments of Health 30,609 95,937 2,756 17,444 156,609 131,220 226,454 640,672 534,482 17%
LHW* 8,162 36,331 735 6,606 143,856 77,121 184,205 452,239 412,522 13%
LHV* 14,284 47,117 1,286 8,567 12,753 33,956 32,109 139,979 88,671 3%
Basic health unit 6,122 12,489 551 2,271 - 20,143 8,450 48,454 31,415 1%
Other public 2,041 - 184 - - - 1,690 - 1,874 0%

Private Sector 526,450 232,181 47,381 42,215 159,670 240,570 463,048 1,620,522 952,883 31%
Private/NGO hospital/clinic 465,235 196,417 41,871 35,712 53,563 117,983 35,489 872,175 284,619 9%
Pharmacy/ Chemists - 3,406 - 619 82,130 15,539 387,000 484,541 485,289 16%
Private doctor 61,215 24,410 5,509 4,438 10,713 70,214 10,140 177,665 101,014 3%
Dispenser/ compounder - 5,109 - 929 10,203 34,532 16,900 64,606 62,563 2%
Other private medical - 2,838 - 516 3,061 2,302 13,520 21,535 19,399 1%

Other Source 36,729 38,034 3,306 6,915 114,778 40,862 942,996 1,162,900 1,108,858 36%
Shop (not pharmacy/ chemist) - - - - 36,729 9,208 515,437 554,531 561,374 18%
Friend/ relative - - - - 21,935 7,482 3,380 32,303 32,797 1%
Dai/traditional birth attendant - 38,034 - 6,915 6,122 7,482 3,380 53,838 23,899 1%
Other - - - - 5,101 - 10,140 16,151 15,241 0%
Don't know 24,486 - 2,204 - 39,280 14,388 405,590 484,541 461,461 15%
Missing 12,243 - 1,102 - 5,611 2,302 5,070 21,535 14,085 0%

Total 2,040,505 567,679 183,645 103,214 510,126 575,527 1,689,957 5,383,794 3,062,470

S-13
* RHSC = reproductive health service centre; MCH = maternal and child health; LHW = lady health worker; LHV = lady health visitor; IUD = intrauterine contraceptive device .
S-14 A. A. Khan, K. Abbas, H. B. Hamza, et al.

Table-2: Percentage change in method mix from 1990 to 2007and the adjusted method mix (2007).

2007 Proportion of all Method Number of women Service mix (Services

Populationa MWRA (%) mix (%) served in last one year delivered in one year) (%)

Not using any contraception 18,616,206 78 - - -

Pills 510,126 2 10 510,126 17
Injections 575,527 2 11 575,527 19
Condoms 1,689,957 7 31 1,689,957 55
IUDs* 567,679 2 11 103,214 3
Female sterilization 2,040,505 9 38 183,645 6
Total 24,000,000 100 3,062,470
*IUD= intrauterine contraceptive device.
αEstimated by the Pakistan Census Bureau, based on extrapolation on the 1998 census.

about the use of these methods. This limited scope of services went unnoticed partly due to
reliance of CPR. While CPR was low by regional standards,
Discussion it still showed that a third of the women used some FP.
CPR in Pakistan has shown a modest annual increase in Unfortunately 8% of these were using a traditional method
the 6 decades of FP programming. We found that all and 10% were women who had received either sterilization
providers combine to serve 3 million women or around or an IUD in a previous year but were still counted as an FP
12% of MWRA with FP services. Most contraception users user due to longevity of the method. Thus using not only is
buy their methods directly from stores without recourse to CPR misleading when measuring the success of FP
a health provider. These women are therefore not programs, nor does it help with planning for services. In
counselled in the correct use of these methods and don't this paper we demonstrate that looking specifically at the
have recourse when they experience side effects. Many a number of women who avail FP services is a more useful
times these side effects are minor and may not warrant planning and measurement tool.
changing or stopping the method and yet without advice,
many experts feel that this is exactly what happens and Looking at the "service mix" also reveals dominance of short
results in very high levels of method switching among term methods that are controlled by users. It shows self
modern contraception users in Pakistan.18 procured condoms are the commonest method used and
suggests that women are often not using formal providers.
Over the last 5 decades, CPR has increased by an average of This may be due to a lack of access of women/ couples to
around 0.5 percent annually. During this time the role of the providers, a lack of trust in existing providers or because
government has shrunk despite investment of over USD 652
don't find value in existing services. In the public sector,
million in family planning in the past decade (UNFPA data,
most providers and facilities have limited menu of methods
Khan, MA. Personal communication). While much of the
available. The lady health workers of the Health
CPR is due to female sterilization, in effect, very few women
Departments provide condoms and pills and have only
receive this method in any given year. Most women use
recently started carrying injections. They almost nev er ask
condoms, often directly from stores without advice from a
women about or refer them for long term methods. Basic
health provider, suggesting that either they are opting for
Health Units of the Health Departments inconsistently
methods that they can control, don't trust health providers
stock FP supplies and almost never ask women about their
or both. Indirectly this has resulted in a service mix that is
FP needs. The Family Welfare and Reproductive Health
deeply skewed towards short term methods despite the fact
Centres of the Population Welfare Departments are perhaps
that the unmet need for limiting families remains high. 19
the best stocked in terms of contraceptive choices but have
Despite a quarter of the women having an unmet need, the the least "foot traffic" and remain underutilized. Using the
overall service provision is very low, resulting in a low CPR. number women clients of FP services from PDJS suggests
Only around 12% of MWRA — less than half as many as the that on average each of the 3300 Population Welfare
women with an unmet need — receive FP commodities facilities nationwide conducts one sterilization ev ery week
each year and only around 5-6% receive formal FP services and provides one IUD every other week. Similarly, each of
from any public or private provider. Despite considerable the nearly 100,000 lady health workers serves on average 4.3
expenditures, the two government departments of Health women with FP services every year. These limited scope of
and Population Welfare, serve around 2% of MWRA each. services in face of fixed costs mean that public sector is

J Pak Med Assoc (Suppl. 3)

From Contraceptive Prevalence to Family Planning Service Users: Implications for Policy and Programmes S-15
extremely expensive in delivering FP services. Indeed, the the DHS. Future research may include validation of
cost of FP in the public sector is around USD 42 per w oman different national surveys that measure similar indicators
per year or around 10 times higher than regional av erages. such as the CPR but sometimes yield differing results.
However this understanding is only possible when CPR or
FP usage is converted into the number of women being Acknowledgements
served annually. Funding for this work was provided by the USAID grant:
SGAFP/2011/SGF/002 Pakistan. There are no conflicts of
Looking at actual number of women served each year will interest.
not only allow a better understanding of these efficiency
issues, it will also allow for better planning and resource Reference
allocation. Knowing how many women are served by each 1. Moghadam VM, Senftova L. Measuring women's empowerment:
type of provider or facility provides a means to use some participation and rights in civil, political, social, economic, and cultural

evidence in planning for resource allocation based on

domains. International Social Science Journal 2005;57:389-412.
2. The U.S AfIDHPI. How contraceptive use affects maternal
existing service delivery patterns. However, ideally, mortality. 2008. 1013. Ref Type: Online Source.
resource allocation decisions should be local, particularly 3. World Health Organization. Contraceptive prevalence rate. 2006.
following the recent devolution of Health and Population
World Health Organization. Ref Type: Online Source.

Welfare to provinces from the federal levels. Thus, knowing

4. World Bank. World development indicators and global development
finance. 2012. The World Bank. Ref Type: Online Source.
usage patterns of individual districts or better still of 5. The World Bank. Unmet need for contraception. 2012. The World
individual facilities will allow for more efficient allocation Bank., The World Bank. Ref Type: Online Source.
of supplies and personnel and for institution of remedies in
6. Rukanuddin AR, Hardee-Cleaveland K. Can Family Planning

case of underperformance. It will also allow NGOs, donors

Succeed in Pakistan? International Family Planning Perspectives
1992 Sep;18(3):109-15.
and private sector to understand what services are available 7. Robinson WC, Shah MA, Shah NM. The Family Planning Program in
in individual locations and where are the gaps. In order for Pakistan: What Went Wrong? Int Fam Planning Perspectives 1981

such information to be available, national surveys such as

Sep;7(3):85-92.
8. National Institute of Population Studies P, Macro International I.
the Demographic Health Survey that was used for this Pakistan Demographic and Health Survey 2006-7. 2008 Jun.
study, will have to be powered to provide such information 9. CaldwellJ.C., Orubuloye IO, Caldwell P. Fertility decline in Africa: A
at provincial, district and even sub-district levels. The new type of transition? Population and Development Review

current DHS data has limited power to do so. For example,

1992;18:211-42.
10. WHO. Contraceptive prevalence rate . 2006. World Health
we were unable to estimate service distribution patterns at Organization. Ref Type: Online Source.
provincial levels due to insufficient sample size. This lack of 11. Abbasi-Shavazi M.J., Mehryar A.H., Jones G., McDonald P.
power must be addressed for future surveys and if these
Revolution, war and modernization: Population policy and fertility

surveys are to be used to understand, measure or plan

change in Iran. Journal of Population Research 2002;19(1):25-46.
12. Santhya KG. Changing family planning scenario in India: An
ongoing services, they must be conducted regularly enough overview of recent evidence. New Dehli, India: Population
to provide these information at appropriate interv als. Council; 2003. Report No.: 17.
13. Population Reference Bureau. Contraceptive use among married
Our study used existing data from the most recent women age 15-49, by method mix. 2008. Population Reference

Pakistan Demographic Health Survey to quantify FP

Bureau. Ref Type: Online Source.
14. Ministry of Health. Improving health outcomes: The principles and
services. This analysis allows a more accurate evidence base for state RCH II programme implementation plans
understanding of quantum of and gaps in FP services than (PIPS). 2007. India, RCH II programme implementation plans
merely looking at changes in CPR. In order to be useful for (PIPS). Chapter 1. Ref Type: Online Source.

measuring existing services and to plan future ones,

15. Rukanuddin AR., Hardee-Cleaveland K. Can Family Planning
Succeed in Pakistan? International Family Planning Perspectives
surveys from which data are taken must be sufficiently 1992;18:109-15.
powered at sub-district levels. More importantly, these 16. The Oxford Policy Management Group. The Third Party Evaluation
and similar analyses must be routinely conducted within
of the Lady Health Worker Program. 2009.

the public sector and the academia as repeated cycles of

17. Dawn News. Devolution of health ministries to be complete by
June 30. Dawn News 2011 May 18.
analyses and feedback will improve data quality and 18. Sathar ZA, Singh S, Fikree FF. Estimating the incidence of abortion
make data more user friendly. Other applications of this in Pakistan. Stud Fam Plann 2007 Mar;38(1):11-22.
technique may be in understanding quantum of other
19. Research and Development Solutions. Policy Brief Series No. 06:

services such as skilled birthing that are also measured by

Understanding Unmet Need for Family Planning in Pakistan. 3-12-
2012. Ref Type: Pamphlet.

Vol. 63, No. 4 (Suppl. 3), April 2013