Azmat et al. Reproductive Health (2015) 12:25 DOI 10.1186/s12978-015-0016-9
RESEARCH
Open Access
Assessing predictors of contraceptive use and demand for family planning services in underserved areas of Punjab province in Pakistan: results of a cross-sectional baseline survey Syed Khurram Azmat1,3, Moazzam Ali2*, Muhammad Ishaque3, Ghulam Mustafa3, Waqas Hameed3, Omar Farooq Khan3, Ghazunfer Abbas3, Marleen Temmerman1,2 and Erik Munroe4
Abstract Background: Although Pakistan was one of the first countries in Asia to launch national family planning programs, current modern contraceptive use stands at only 26% with a method mix skewed toward short-acting and permanent methods. As part of a multiyear operational research study, a baseline survey was conducted to understand the predictors of contraceptive use and demand for family planning services in underserved areas of Punjab province in Pakistan. This paper presents the baseline survey results; the outcomes of the intervention will be presented in a separate paper after the study has been completed. Method: A cross-sectional baseline household survey was conducted with randomly selected 3,998 married women of reproductive age (MWRA) in the Chakwal, Mianwali, and Bhakkar districts of Punjab. The data were analyzed on SPSS 17.0 using simple descriptive and logistic regression. Results: Most of the women had low socio-economic status and were younger than 30 years of age. Four-fifths of the women consulted private sector health facilities for reproductive health services; proximity, availability of services, and good reputation of the provider were the main predicators for choosing the facilities. Husbands were reported as the key decision maker regarding health-seeking and family planning uptake. Overall, the current contraceptive use ranged from 17% to 21% across the districts: condoms and female sterilization were widely used methods. Woman’s age, husband’s education, wealth quintiles, spousal communication, location of last delivery, and favorable attitude toward contraception have an association with current contraceptive use. Unmet need for contraception was 40.6%, 36.6%, and 31.9% in Chakwal, Mianwali, and Bhakkar, respectively. Notably, more than one fifth of the women across the districts expressed willingness to use quality, affordable long-term family planning services in the future. Conclusion: The baseline results highlight the need for quality, affordable long-term family planning services close to women’s homes. Furthermore, targeted community mobilization and behavior change efforts can lead to increased awareness, acceptability, and use of family planning and birth spacing services.
* Correspondence: [emailprotected] 2 Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland Full list of author information is available at the end of the article © 2015 Azmat et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Azmat et al. Reproductive Health (2015) 12:25
Background Family planning (FP) is one of the most “health-promoting” and cost-effective activities in public health promotion and has the potential to avert approximately 30% of maternal and 10% of child deaths [1]. Thus, FP contributes to achieving the Millennium Development Goals (MDGs) through healthier birth spacing and by reducing mortality and morbidity associated with pregnancy [2]. In 1950, Pakistan had a population of 37 million and was the world’s 13th largest country as measured by population; however, in 2013, Pakistan had become the sixth largest country with 191 million people [3]. The first government-supported family planning program was started in the 1960s, but over a 50-year period, priorities changed as the program evolved. Failure to effectively manage the fertility rate and rapid population growth had adverse effects on development indicators such as education, poverty, and life expectancy, particularly for maternal and child health [4]. In Pakistan, approximately 35% (more than 8 million) of married women of reproductive age (MWRA) practice some form of family planning, and of them, around 26% (6 million women) use a modern method [5]. Among modern methods, female sterilization/tubal ligation is the most common method at around 45% of the modern method mix, but it is chosen late, often after 31.5 years of age and usually after four or more children [5]. Second, short-term methods such as condoms accounted for around 23% of the method mix, with the remainder divided between the pill, injection, and long-term method (LTM) for contraception, i.e., an intrauterine contraceptive device (IUCD): 8%, 7%, and 17%, respectively [5]. A Pakistani woman does not enjoy autonomy of decision making regarding her own reproductive health and family planning needs [6]. Moreover, religious opposition and misinterpretation of family planning impede the adoption of contraceptives, even among those who desperately want to space their children [7]. Pakistan is a signatory to the International Conference on Population and Development (ICPD). To achieve the country’s commitment to the global MDGs to lower the fertility rate, slow the rapid population growth, and decrease maternal, neonatal, and child morbidity and mortality, the government of Pakistan pledged to increase the contraceptive prevalence rate to 55% by 2015 [8]. However, with the prevailing scenario, it is improbable that this goal will be achieved, although the government of Pakistan is still the major FP provider in Pakistan (47%) while 23% of the need is fulfilled by the private sector [5]. Importantly, 53% of the LTM is supplied by the public sector, but their contribution in the modern contraceptive prevalence rate (CPR) is only 2.3% [5]. Thus, concentrated efforts are required to utilize all available channels in the public, private, and nongovernmental
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organization (NGO) sectors to address the low and very slowly progressing CPR and high unmet need for family planning in Pakistan since only with public and private sector collaboration can this challenging goal be achieved. In the present scenario, franchised health establishments are becoming popular worldwide in attracting reproductive health clients [9]. The Marie Stopes Society (MSS), a local non-governmental organization, therefore, originally piloted its own version of social franchise intervention as Suraj (i.e., in English, Sun, a brand name provided to the clinics of the trained franchise providers of MSS) in 2008 to improve the reproductive health of women living in rural communities and to test the intervention’s feasibility [10]. The earlier findings documented increased awareness and modern contraceptive use especially of IUCDs in targeted rural poor communities in a few districts in Punjab and Sindh provinces [10,11]. Thus, with slight modifications of the original MSS Suraj social franchise model [10-12], the MSS implemented a new operational research project, with a quasi-experimental study design. Based on a similar social franchising model with a demand-side financing approach, the MSS built a partnership with local health care providers in underserved rural areas of Pakistan to produce robust results within a minimum period of time to increase the targeted CPR among the poorest [12]. As part of this multiyear operational research study, a baseline survey was conducted in May 2012 to understand the predicators of contraceptive use and demand for family planning services in underserved areas of Punjab province in Pakistan. This paper presents the survey results; the outcomes of the intervention will be presented in a separate paper after the study has been completed. It is anticipated that the baseline findings will inform the operations research project implementation and programmatic decision making to ensure that the project is on track and adequately meets the contextualized supply and demand needs in the targeted areas. Moreover, the baseline survey will serve as a benchmark to assess the effect of the intervention. The end-line survey of this project will be conducted after the 24-month intervention has been completed to measure change in key project indicators as a result of the intervention.
Methodology Study design
This is a quasi-experimental study with a control arm. Data collection methods include population-based household surveys (baseline and end-line). Study settings
The survey was conducted in two intervention districts (Chakwal and Mianwali) and the control district (Bhakkar), where the control district was selected based on its
Azmat et al. Reproductive Health (2015) 12:25
proximity and comparability to demographic and service delivery indicators of the intervention areas. The control district is at a sufficient distance from the intervention districts to any contain spillover effect of the intervention.
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decision-making dynamics regarding health seeking, family planning, pregnancy, and delivery; and spousal communication regarding family planning and birth spacing. Statistical analysis
Sampling
The multi-stage sampling technique was used to select respondents. At the first stage, the districts and catchment area of the providers were purposively selected. The catchment area for the providers spread over 3–4 km radius and were at a sufficient distance from one another. After demarcation of the catchment area, all households within the catchment area of each service provider were allotted a unique study number in order to select the households for the baseline survey. Using computer software, we randomly selected a sample of households within the catchment of each service provider. Sample size
Data were analyzed using SPSS 17.0. Descriptive statistics, frequencies, and proportion were run based on the respondents’ socio-demographic characteristics, reproductive health care profile, decision making, contraceptive knowledge, attitude, and practice. The mean, median, and standard deviation were calculated for the continuous variables and proportions for the categorical variables. Table 1 Socio-demographic characteristics of MWRA Characteristics
Chakwal %
Mianwali %
Bhakkar %
15.3
16.3
15.5
Age of women ≤24
The target population for the baseline survey included MWRA (15–49 years). Overall, a total of 3,998 MWRA were interviewed: 694 in Chakwal, 719 in Mianwali, and 2,585 in Bhakkar. One MWRA was interviewed in a household. If more than one MWRA was found within a household, then the youngest MWRA was interviewed.
>24 to 35
43.2
45.3
53.3
>35
41.5
38.4
31.2
Average ± SD
32.4 ± 7.4
31.2 ± 7.1
30.3 ± 6.3
Age of women at marriage ≤20
67.4
65.0
65.7
>20 to 25
25.9
26.6
29.8
Tool for baseline survey
>25
6.6
8.5
4.4
The survey questionnaire was adapted from the 2006–07 Pakistan Demographic Health Survey (PDHS) instruments. The questionnaire had two components: the demographic and socio-economic characteristics of women and one that explored fertility choices, contraceptive knowledge, and practices and aspects of reproductive health.
Average ± SD
19.8 ± 3.7
20.2 ± 3.8
19.9 ± 3.3
35
1,591
297 (18.7)
1.90 (1.45-2.48)***
>25
250
26 (10.4)
1
1
>20 to 25
1,141
159 (13.9)
1.42 (0.91-2.20)
1.01 (0.60-1.74)
≤20
2,039
583 (19.2)
2.07 (1.37-3.15)***
1.18 (0.70-1.98)
1,002
129 (12.9)
1
1
Age of women at time of marriage
Age of husband
