Determining the factors associated with Unmet need for family planning: A cross-sectional survey in 49 districts of Pakistan

Introduction & Background: Around 137 million women in the developing world who would like to avoid childbearing are unable to do so, despite a huge increase in contraceptive access and use globally. Ironically, the prevalence of unmet need in Pakistan is among the highest in the world despite being one of the first countries in South Asia to launch national family planning program. The aim of this paper is to estimate the prevalence of unmet need for contraception and to indentify the factors associated with it.Methods: A cross-sectional survey was conducted in forty nine districts of Pakistan across all four provinces from September 2008 to March 2009. Using an adapted version of PDHS questionnaire, interviews were conducted with approximately 10,000 married women of reproductive age in each district. Sample was later weighted according to district population at the time of analysis to control over and under representation. Logistic regression analysis was used to assess the association between risk factors and unmet need.Results: The total unmet need for contraception was 23.5%. Multivariable analysis showed that unmet need was found significantly higher in Balochistan and Sindh province compare to Punjab. The unmet need was quite prevalent among the specific groups that include older age women, low or uneducated women, those who have higher number of living children, had no history of miscarriage or abortion, those who are not exposed to mass media once a week, and among the women in lowest wealth quintiles.Conclusion: Despite all the efforts made to increase in uptake of contraceptive method the contraceptive prevalence rate has hardly changed over the last decade. However, several groups of women continue to have high unmet need for family planning. Thus, the family planning programmes may need to shift their focus from increasing uptake of contraceptives to satisfying unmet need for contraception with special focus on those underserved marginalized groups and areas with highest levels of unmet need

Post-abortion care family planning use in Pakistan

Introduction: The stagnated CPR and high unmet need for contraception lead to approximately 890,000 induced abortions every year in Pakistan. A fairly recent study from Pakistan also revealed that around 40% of abortions are performed by unskilled workers in backstreet clinics. Considering these grave statistics, it should not come as surprise that unwanted pregnancies are the leading cause of induced abortions in Pakistan. Despite country\u27s inferior situation, there is no data available in Pakistan that unveils the much needed information pertaining to post-abortion care family planning (PAC) use. Thus, this paper attempts to document socio-demographic profile seeking post-abortion care clients; estimate proportion of post-abortion contraception uptake and determine its associated factors.Methods: Medical records of 17,262 women seeking PAC as a result of incomplete abortion and treatment for complications arising from unsafe abortions were analyzed. The associations between risk factors and post-abortion family planning uptake were assessed by applying univariate and multivariable logistic regression.Results: High post abortion contraceptive use (72.9%) was observed amongst the women who had sought for PAC services. where, 66% of the women opted to use short-term methods. The rest (33.5) considered long-term reversible IUD and implant as their method of choice and only 0.4% had undergone voluntary sterilization. Multiple logistic model identified province, women education, women occupation status, monthly family income, first time visitors to the centre, previous contraceptive use, and type of PAC treatment provided, women\u27s health condition after post-abortion treatment had significant associations with the uptake of contraception.Conclusion: The present study highlights the importance of strengthening post-abortion family planning services in the country which will not only contribute in increasing the overall contraceptive use in the country but will also prevent high unintended pregnancies that may ultimately lead to induced abortions

Barriers and perceptions regarding different contraceptives and family planning practices amongst men and women of reproductive age in rural Pakistan: A qualitative study

Background: Pakistan ranks as one of the most poorest and most populous in the world with poor reproductive health indicators. This study helps in understanding barriers and perceptions regarding Family Planning (FP), modern contraception, quality of care and free of charge FP services amongst men and women in rural Pakistan.Methods: Employing purposive sampling and Focus Group Discussion (FGD) technique, this qualitative study was conducted with men and women of reproductive age in Pakistan. A total of eight FGDs were conducted in Sindh and Punjab provinces. Being descriptive in nature, the study provided a thematic analysis of the relevant health issues by using an adapted constant comparison analysis process.Results: The contraceptive knowledge and uptake was low and misinformation was prevalent. Men thought of vasectomy as against men\u27 pride and both males and females viewed removal of uterus as a permanent method. The women claimed neighbors, mother-in-law, friends and sister in-law and husband as main sources of information. Women seemed to have a greater exposure since they regularly come into contact with lady health workers and lady doctors but that information is not passed on to their husbands or discussed openly. There were many misconceptions prevalent among the participants, most of which were spread by untrained providers, such as the undesirable impact contraception can have on a woman\u27s ability to conceive children. In addition, restrictions on female mobility and side effects were seen as barriers to contraception by majority of women whereas, most of the men perceived religio-cultural factors as barriers and considered FP as an additional expenditure.Conclusions: Though importance of family planning was recognized by the participants for the well being of the children and financial benefits of raising fewer children but the wellbeing of the woman was not considered a meaningful goal to pursue FP. Besides access, barriers towards use included money, where frequency of use and choice of method was affected by financial limitation. A gendered perspective also prevailed with reference to provider seeking behavior. Spousal communication is a topic mostly neglected by family planning programs, yet many of the barriers are linked to it. There is a need to design health interventions that devise counseling techniques to improve spousal communication, debunk the myths and misinformation in the community, and link the health of the child and mother with birth spacing and smaller family size

Development of niosomal formulations loaded with cyclosporine A and evaluation of its compatibility

Purpose: To formulate niosomes of cyclosporine A using nonionic surfactants, and to use the attenuated total reflectance/Fourier transform infrared (ATR-FTIR) technique to explore solid/liquid interfacial phenomena as well as compatibility between active drug and pharmaceutical excipients.Methods: Niosomes of cyclosporine A were prepared using the thin-film hydration method. Cholesterol and non-ionic surfactants, including polyethylene glycol sorbitan monostearate (Tween 60) and sorbitan monostearate (Span 60), were used as excipients. The ATR-FTIR spectra of all the ingredients, their physical mixtures, and niosomal formulations were studied. The niosomes were characterized for size, polydispersivity index (PDI), zeta potential, and entrapment efficiency.Results: Six niosomal formulations (F1 – F6) were successfully developed. Niosomal formulation F2 prepared at the ratio of 6:4 surfactant to cholesterol, presented the highest entrapment efficiency of 77.28 %. The ATR-FTIR spectra of niosomal formulations did not show incompatibility. The size of the selected formulation (F2) was 1049 nm while its SEM image displayed a spherical nature of the niosomes.Conclusion: The results show that cyclosporine A can be entrapped in niosomes using non-ionic surfactants and cholesterol. Furthermore, there is no significant interaction between the ingredients of niosomes and cyclosporine A.Keywords: Cyclosporine A, Attenuated total reflectance Fourier transform infrared spectroscopy), Niosomes, Compatibility, Non-ionic surfactant

Hydrophilic polymers based sustained release matrix tablets of Ibuprofen: Optimization of formulation using Box-Behnken statistical design

The current study was aimed to formulate sustained release matrix tablets of Ibuprofen; a Propionic acid derivative, and is non-steroidal anti-inflammatory agent (NSAID) with analgesic and antipyretic properties and optimize by using a 3-factor 3-level Box-Behnken statistical design as an optimization tool. Matrix tablets were prepared by direct compression technique using HPMC(X1), NaCMC(X2) and Xanthan Gum(X3) as independent variables and % release at 2hr (Y1), % release at 12hr (Y2) and hardness (Y3) of tablet were selected as dependent variables. Regression analysis was performed on dissolution data and construct polynomial regression models for these response variables. Polynomial models were further validated using ANOVA and results indicate that all the polymers used have significant effect on selected response (p<0.05). Contour plots were drawn to evaluate the effect of polymer combination on selected responses. The results obtained from kinetic modeling indicate that drug release follows the non-fickian diffusion process. Hence Box-Behnken statistical design facilitates the formulation and optimization of Ibuprofen sustained release matrix tablets to achieve better bioavailability. Keywords: Matrix tablets, Sustained release, Ibuprofen, Ant-inflammatory, Box-Behnken statistical desig

Family planning knowledge, attitudes, and practices among married men and women in rural areas of Pakistan: Findings from a qualitative need assessment study

This paper presents the findings of a qualitative assessment aimed at exploring knowledge, attitudes, and practices regarding family planning and factors that influence the need for and use of modern contraceptives. A descriptive exploratory study was conducted with married women and men aged between 15 and 40. Overall, 24 focus group discussions were conducted with male and female participants in three provinces of Pakistan. The findings reveal that the majority knew about some modern contraceptive methods, but the overall contraceptive use was very low. Knowledge and use of any contraceptive method were particularly low. Reasons for not using family planning and modern contraception included incomplete family size, negative perceptions, in-laws\u27 disapproval, religious concerns, side-effects, and lack of access to quality services. The majority preferred private facilities over the government health facilities as the later were cited as derided. The study concluded the need for qualified female healthcare providers, especially for long term family planning services at health facilities instead of camps arranged occasionally. Addressing issues around access, affordability, availability, and sociocultural barriers about modern contraception as well as involving men will help to meet the needs and ensure that the women and couples fulfill their childbearing and reproductive health goals

Comparing effectiveness of two client follow-up approaches in sustaining the use of Long Acting Reversible Contraceptives (LARC) among the underserved in rural Punjab, Pakistan : a study protocol and participants' profile

Background: Pakistan observes a very high i.e. 37 percent modern contraceptive method related discontinuation rates within 12 months of their initiation. And almost 10 percent of these episodes of discontinuation happened due to the side effects or health concerns experienced by the women. Most importantly, it was noted that more than 12,000 first-level care facilities are located in the rural areas, including rural health centers, basic health units, and family welfare centers, but more than 30% of these facilities are nonfunctional. This paper presents a study protocol and participants' profiling of a prospective cohort follow-up to compare the effectiveness of household based and telephonic approaches in sustaining the use of Long Acting Reversible Contraceptives (LARC) whilst to facilitate lowering method related discontinuation and increasing switching amongst the contraceptive users. Methods: A 12-month multi-centre, non-inferiority prospective user follow-up is employed using three different study categories: a) household based follow-up; b) telephonic follow-up; and c) passive or need-based follow-up along with the hypothetical assumption that the telephonic client follow-up is not inferior to the household based follow-up by continuation rate of LARC and the telephonic follow-up is less-costly than the household based client follow-up. This follow-up will be conducted in 22 health facilities -(16 rural and 6 urban based facilities) in district Chakwal. The first two study categories will receive scheduled but different follow-up from the field workers at 1, 3, 6, 9, and 12 month while the third one i.e. the 'passive or need-based follow-up' will serve as a control group. Using sampling software PASS 11, it was estimated to have 414 clients in each study category and around 1366 clients will be recruited to account for 10% attrition rate. Discussion: The study will help us to examine a more convenient method of effective follow-up for managing side effects, decreasing method discontinuation and increasing switching amongst users. The study information will also facilitate to develop a robust, effective and efficient mechanism for client follow-up to promote the continuation rates of LARC methods. The follow-up results and lessons learnt will be widely shared with stakeholders for their implementation and streamlining in health system

Determinants of method switching among social franchise clients who discontinued the use of intrauterine contraceptive device

Introduction: Women who do not switch to alternatemethods after contraceptive discontinuation, for reasons other than the desire to get pregnant or not needing it, are at obvious risk for unplanned pregnancies or unwanted births. This paper examines the factors that influence women to switch from Intrauterine Contraceptive Device (IUCD) to other methods instead of terminating contraceptive usage altogether. Methods: The data used for this study comes from a larger cross-sectional survey conducted in nine (9) randomly selected districts of Sindh and Punjab provinces of Pakistan, during January 2011. Using Stata 11.2, we analyzed data on 333 women, who reported the removal of IUCDs due to reasons other than the desire to get pregnant. Results: We found that 39.9% of the women do not switch to another method of contraception within one month after IUCD discontinuation. Use of contraception before IUCD insertion increases the odds for method switching by 2.26 times after removal. Similarly, postremoval follow-up by community health worker doubles (OR = 2.0) the chances of method switching. Compared with women who received free IUCD service (via voucher scheme), the method switching is 2.01 times higher among women who had paid for IUCD insertion. Conclusion: To increase the likelihood of method switching among IUCD discontinuers this study emphasizes the need for postremoval client counseling, follow-up by healthcare provider, improved choices to a wider range of contraceptives for poor clients, and user satisfaction

Comparing effectiveness of two client follow-up approaches in sustaining the use of long acting reversible contraceptives (LARC) among the underserved in rural Punjab, Pakistan: A study protocol and participants\u27 profile

Background: Pakistan observes a very high i.e. 37 percent modern contraceptive method related discontinuation rates within 12 months of their initiation. And almost 10 percent of these episodes of discontinuation happened due to the side effects or health concerns experienced by the women. Most importantly, it was noted that more than 12,000 first-level care facilities are located in the rural areas, including rural health centers, basic health units, and family welfare centers, but more than 30% of these facilities are nonfunctional. This paper presents a study protocol and participants\u27 profiling of a prospective cohort follow-up to compare the effectiveness of household based and telephonic approaches in sustaining the use of Long Acting Reversible Contraceptives (LARC) whilst to facilitate lowering method related discontinuation and increasing switching amongst the contraceptive users.Methods: A 12-month multi-centre, non-inferiority prospective user follow-up is employed using three different study categories: a) household based follow-up; b) telephonic follow-up; and c) passive or need-based follow-up along with the hypothetical assumption that the telephonic client follow-up is not inferior to the household based follow-up by continuation rate of LARC and the telephonic follow-up is less-costly than the household based client follow-up. This follow-up will be conducted in 22 health facilities - (16 rural and 6 urban based facilities) in district Chakwal. The first two study categories will receive scheduled but different follow-up from the field workers at 1, 3, 6, 9, and 12 month while the third one i.e. the \u27passive or need-based follow-up\u27 will serve as a control group. Using sampling software PASS 11, it was estimated to have 414 clients in each study category and around 1366 clients will be recruited to account for 10% attrition rate.Discussion: The study will help us to examine a more convenient method of effective follow-up for managing side effects, decreasing method discontinuation and increasing switching amongst users. The study information will also facilitate to develop a robust, effective and efficient mechanism for client follow-up to promote the continuation rates of LARC methods. The follow-up results and lessons learnt will be widely shared with stakeholders for their implementation and streamlining in health system