Afghanistan and Pakistan move slow on family planning

Karachi: Getting the family planning message out among the estimated two million internally displaced persons (IDPs) in North West Frontier Province (NWFP) has not been a top priority, according to a senior health official from Punjab Province.

Average Afghan woman gives birth to 6-7 children, according to UNFPA/ Photo credit: IRIN

Islam Zafar, director of health in the province, is currently leading a team of 140 paramedics running a hospital for IDPs in Mardan District, NWFP.

“We’re trying not to topple the applecart by promoting family planning messages (among IDPs),” he said.

Doctors had been concentrating on saving lives, obstetric care and immunisation activities rather than taking up “the more culturally and religiously sensitive” issue of contraceptives, Zafar said.

“It is not easy to work in this conservative area and we must not be seen as interfering with their culture,” he added.

The Mardan Medical Complex, where Zafar and his team are working, was opened on 20 May, and has a state-of-the-art-gynaecological ward. In part this is the result of efforts by the Punjab chief minister, Shahbaz Sharif, to boost quality healthcare for IDPs, especially mothers and children.

According to the Reproductive Health and Family Planning Survey conducted in 2000-01 by Pakistan’s National Institute of Population Studies, Pakistan’s fertility rate was estimated at 4.8 (the average number of children born to a woman over her lifetime), with a slightly higher figure (5.1) for NWFP.

Some experts say high maternal and child mortality rates are related to high fertility rates and poor access to health services before and during deliveries.

Missed opportunity?

Khalid Khan, a UN Population Fund (UNFPA) district project officer working with IDPs, described the current IDP situation with regard to family planning as “a missed opportunity”.

It has not been possible to “actively” promote family planning (FP) practices in the more than 20 camps because medical staff did not want to “face unnecessary resistance” from the IDPs, many of whom are not accustomed to discuss the issue openly, Khan said.

“The cultural and religious taboos stop us from actively promoting this.”

However, UNFPA is working with the NWFP government’s Population Welfare Department to provide services to all those seeking them. It has a well-equipped pharmacy in Yar Hussain camp, in Swabi District, not far from Mardan, where all kinds of contraceptives – injectibles, intrauterine contraceptive devices (IUCDs), pills and condoms - are available, according to Khan.

“Some women have come to us for injections, some for insertion of the IUCD and some for pills,” said Tahera Bano, a lady health visitor working with UNFPA at Yar Hussain camp.

She said some female IDPs were familiar with various contraceptive methods but not aware that contraceptives and advice were available for free in the camps. Around 24,000 IDPs are believed to be living in Yar Hussain camp.

Dilraz Khakistar is a UNFPA female welfare councillor at the camp and her job is to go round the tents and try and talk to women about FP methods.

“In between encouraging them to come for antenatal and postnatal checkups, and vaccinations, I slide in FP messages too,” she said, adding: “All my efforts come to nothing when women turn around and say they want to have 5-10 children.”

Disparity in family planning in Afghanistan

Family planning services are available in over 90% of health facilities across Afghanistan but the number of women using them in rural areas is too low, according to the Ministry of Public Health (MoPH).

Hamida Ebadi, director of MoPH’s reproductive health unit, reckoned only 14-15% of women in rural and remote regions use family planning services.

“The number of women using these services in urban areas is higher than in rural areas but we don’t have formal statistics to show the disparity,” Ebadi said in Kabul.

Several NGOs and the MoPH are involved in the delivery of family planning services, which include professional advice on gaps between pregnancies and free distribution of contraceptives, including condoms, tablets and injections.

Second only to Sierra Leon, Afghanistan has one of the highest maternal mortality ratios in the world with 1,600 deaths per 100,000 live births (24,000 preventable deaths every year), according to the UN Population Fund (UNFPA).

Most pregnancy-related deaths happen in remote, isolated and insecure areas of the country where people have poor access to quality health services, officials say.

Taboo

“The majority of people here are not familiar with family planning and contraceptives,” said Narghes Azimi, a health worker in the southern province of Kandahar.

“Sex and contraceptives are strong taboos here,” she said.

Lack of awareness and strong conservative traditions which often hamper women’s access to health centres are major reasons why family planning measures are not making much headway in the countryside, health experts say.

“Lack of female health personnel also inhibit women’s access to health services because many men do not permit women to be seen by a male doctor or nurse,” said Hamida Elmi, head of an obstetric hospital in the northern city of Mazar-i-Sharif.

Backed by the government, UNFPA has been training imams from around the country on the benefits of family planning and pregnancy gaps in a bid to increase public awareness and reduce pregnancy-related maternal deaths.

However, health officials acknowledge the problems of reproductive health in rural areas go far beyond a lack of awareness or restrictive traditions.

Insecurity, the high prevalence of child marriages, the dearth of professional female health workers particularly outside urban areas, and the lack of roads in remote areas are some of the big challenges contributing to high maternal and infant mortality and morbidity, MoPH officials say.

Birth spacing

Birth spacing through better pregnancy planning and the use of contraceptives is recommended by health experts and is believed to be instrumental in curbing preventable maternal mortality.

“Children, whose mothers die, are 10 times more at risk of dying compared to children who are cared for and fed by their own mothers,” said Health Minister Amin Fatimie.

Birth spacing is also believed to lead to improved infant health, experts say.

Largely owing to donor funding, the country has made progress in reducing infant mortality from 165 deaths per 1,000 live births in 2001 to about 129 in 2006, according to the UN Children’s Fund (UNICEF).

Maternal health has also improved due to extended health services, but no formal assessments have been conducted to illustrate the progress.

Challenges ahead

However, significant challenges lie ahead given that Afghanistan has the highest fertility rate in Asia and the average Afghan woman gives birth to 6-7 children, according to UNFPA.

Ranked the fifth least developed country by the UN Development Programme (UNDP) in 2007, Afghanistan’s current estimated population of more than 28 million is anticipated to exceed 56 million by 2050, which could create enormous social, health and developmental challenges.