Family planning in India and Pakistan: Picking up the pace of change

Birula, living in Bihar, India, was all smiles about her sterilization. 
Photo: David J. Olson

This blog was originally published by Global Health TV on Jan. 27, 2015.

WALLAH, Pakistan and ARA, India -- Last month, I met Sumeera, 26, in a Dhanak clinic (“dhanak” means rainbow in Urdu) in the village of Wallah, in the rural Punjab of Pakistan. She and her husband have four children ages 7, 5, 3 and 1, and have agreed that four is enough. She had come for a pregnancy test and to secure a contraceptive method to keep her family from getting bigger. Her pregnancy test was negative, and she went away happily, with an intrauterine device inserted by her Dhanak midwife and clinic owner Kaneez Fatima. “Before we found Dhanak, my husband and I knew about family planning but did not have access to it,” Sumeera told me. “Dhanak made a big change in my life.”

One thousand four hundred kilometers to the southeast and a week later, I met Birula, 25, in a Surya clinic (“surya” is the Hindi word for sun) in Ara, a rural town about two hours outside of Patna, India, the capital of Bihar state. She has three children ages 7, 6 and 1½. The previous week she had been sterilized at this clinic; she was back to have her stitches removed. Her relief was palpable – she couldn’t stop smiling.

Sumeera and Birula come from different cultures in different countries but the problems they face are remarkably similar – too many children and too little ability to control the size of their. In India, women cannot always determine the size of their families because of a strong preference for the male child and male dominance in decision-making. In Pakistan, religion also plays an influential role. Both countries are confronting the problem, albeit in different ways and with varying degrees of success.

India, the second largest country in the world, has a population of 1.3 billion, and Pakistan has 194 million, making it number six. If current trends continue, India will overtake China to become the world’s largest country, and Pakistan the fifth biggest, by 2050, according to the Population Reference Bureau. But governments of both countries are determined that current trends will not stand and are trying to change the momentum.

India is far ahead of Pakistan in terms of progress in family planning. The fertility rate (the average number of children a woman has in her lifetime) is 3.8 in India and 2.7 in Pakistan. In India, the contraceptive prevalence rate for modern methods is 48.5% (and will likely be higher than that when the 2014-15 Demographic and Health Survey comes out later this year) and 26.1% in Pakistan.

Dhanak and Surya networks are both programs of DKT International, a non-profit organization based in Washington, D.C. that makes family planning, reproductive health and HIV prevention products and services available to low-income populations through social marketing and social franchising. I was in Pakistan and India to visit both programs.

DKT’s Janani program, one of its oldest, works in Bihar, Jharkhand, Madhya Pradesh, Uttar Pradesh, Chhattisgarh, Assam and West Bengal providing these products and services through social franchising in Surya clinics (both Janani-owned and franchised clinics) and through social marketing in private sector outlets.

DKT Pakistan, one of DKT’s newest programs, has aggressively built up its network of midwife-owned and operated Dhanak clinics to 600 in only two years. It aims to double that, to 1,200, by the end of 2015. The clinics operate in all parts of Pakistan — from the deserts of Sindh in the south to the snow-capped Himalayan peaks in the north.

The Surya and Dhanak social franchising networks are different in some ways (Dhanak clinics are owned by midwives; Surya clinics are owned by Janani or doctors), but they have more commonalities than differences. They both:

·      Focus intently on rural areas, which is appropriate given that their clientele are overwhelmingly rural (Pakistan is 65% rural and Bihar is 85% rural).

·      Observe franchising principles — standard appearance, signage, advertising, etc.

·      Carry out regular quality assurance to ensure that all clinics meet and maintain high standards of quality.

·      Offer training and refresher training to ensure that their clinical staffs have the skills they need to give optimal health care to their clients.

·      Provide a full line of reproductive health services and products.

Several of the same obstacles to family planning came up in both countries — pressure to have a lot of children and to have at least one male child. In some cases, the pressure is there because they cannot be sure if all of their children will survive. The pressure can come from the husband, the mother-in-law or other family members.

In my brief, unscientific visits, I was pleased to encounter several progressive husbands and mothers-in-law, who supported women’s desire to control the size of their families. I hope this evidence is more than anecdotal.

Almost 20 years ago, the study “Factors Affecting Contraceptive Use in Pakistan” revealed that “knowledge of a source and easy access to a service outlet are strongly related to contraceptive use for both urban and rural women, reinforcing the fact that the availability of and access to services are critical factors for raising the level of contraceptive use.”

That is still true to some extent and but programs such as DKT Pakistan and Janani — and others like them — are working hard to change the dynamic and bring contraception as close as possible to those who need it.