Family planning through the lens of men: Readiness, preferences, and challenges

Family planning (FP) is urgently needed in Pakistan but progress remains slow. In its 2002 Population Policy, the country pledged to reduce its total fertility rate to 2.2 by 2020; at the London Summit in 2012, it committed to increase the contraceptive prevalence rate (CPR) to 55 percent by the same year. Despite important achievements, Pakistan’s current CPR is only 35 percent, the total fertility rate is 3.8, and 20 percent of married couples of reproductive age express unmet need for FP. FP programming has largely been directed at women, and husbands have been regarded, at best, as interested bystanders. However, recent research indicates that men’s attitudes are changing and they are eager to be involved. In several recent studies, the Population Council has focused on men’s perspectives of FP to support an evidence-based agenda that brings men into mainstream FP programming. This policy paper synthesizes the data from these studies, and other research, on Pakistani men’s readiness to be more involved in FP, the challenges they face in FP adoption, and the preparedness of the health sector to respond to their needs

Effect of dai training on maternal and neonatal care: An operations research study

This study examines the use of training traditional birth attendants, or dais as they are known in Pakistan, to reduce maternal mortality. By training dais to adopt safer routine delivery, newborn care practices, and recognize and refer in case of emergencies, dais can improve maternal and neonatal health. While one group of women met with specially trained dais who received Safe Motherhood Applied Research Training (SMART), a control group met with dais who offered health services only. The objectives of this evaluation were to determine whether dais substantially improved their performance after attending the SMART dai training course, to determine their knowledge, attitude and behavior regarding maternal and neonatal health, to assess the skills regarding maternal and neonatal health, and to determine the perceptions of clients regarding practices and behavior of dais who served them. Findings from this study concluded that SMART dai training was sufficiently effective to result in changes and knowledge and behavior in many aspects of maternal and neonatal care, but the testing of the SMART dai approach is needed in other settings

Increasing access to reproductive health care through improved service delivery

The study documented in this report examines the provision and utilization of public and private sector maternal and child health services in Punjab, Pakistan with a focus on family planning (FP) services. It is aimed at enabling a better understanding of the specific demand and supply dynamics leading to low contraceptive prevalence despite unmet need, and the opportunities that must be seized to enhance access to quality family planning services. The report is part of a larger project being implemented by the Population Council with the assistance of the Department for International Development, UK entitled “Sustaining Focus on Provincial Governments for FP 2020 Goals and Increasing Access to Reproductive Healthcare through Improved Service Delivery.” The findings of the study suggest that there is scope for improving delivery of FP services and methods through all four major sectors, i.e., the public health facilities, the private health facilities, Lady Health Workers, and pharmacies. Based on its findings, the report recommends specific measures and approaches to address unmet need for family planning and the skewed method mix in Punjab

Safe Motherhood Applied Research and Training (SMART) Report 2: The interventions

The Safe Motherhood Applied Research and Training (SMART) project, an operations research project designed to develop and test interventions to reduce maternal, perinatal, and neonatal mortality and morbidity in predominantly rural districts of Pakistan, was a three-year project (2003 to 2006) funded by the European Union. The study area was in the district of Dera Ghazi Khan; the control area was in the district of Layyah. The project focused on three areas to accomplish its goals: empowering women to seek appropriate and timely general, maternal, and newborn care; supporting methods that encourage men to play a positive and active role in decision-making and seeking care for their families in matters relating to maternal and newborn care; and improving and strengthening health services. The project had two intervention sites and one control site to look at the impact of two different interventions (within communities and within health facilities). It was expected that project results would be useful to others working toward reducing maternal, perinatal, and neonatal mortality and morbidity, nationally and internationally. The interventions and findings from this study are published in six reports, of which this is Report 2: The Interventions

Involving Men in Reproductive and Fertility Issues: Insights from Punjab

Pakistan's slackening in its fertility transition is a cause of concern internationally, as well as within the country. This study has a twofold aim of exploring couples' dynamics during decision processes regarding fertility intentions and practices along with community perceptions of male-focused interventions and men's suggestions for future intervention strategies. The findings are based on three data sources. The primary data source is a 2013 qualitative study in four districts of Punjab province. The second data source is secondary analysis of the baseline and end line surveys of the Family Advancement for Life and Health (FALAH 2007-2012) project. The third data source is the Pakistan Demographic Health Survey (PDHS) 1990-1991 and 2006-2007, which were used to assess trends over two decades. The 2013 qualitative study was in four districts of Punjab, namely Jhelum, Bahawalpur, D.G. Khan, and Okara. The first three were FALAH districts in which interventions were tested, while the fourth was chosen as a control district. A total of 12 focus group discussions were conducted with men, and in-depth interviews were conducted with 26 couples in these districts. Data from 2,649 men and 638 couples from the FALAH baseline and end line surveys were analyzed to assess the impact of FALAH male-directed interventions on fertility intentions and behavior. This study seeks to explore the decision-making process of couples in the move from intentions to fertility behavior. It also examines the readiness of men to be involved in family planning (FP) programs through different male-centered interventions. In-depth interviews (IDIs) with couples are especially direct in gauging spousal perception of the partner's FP approval or disapproval. The study focuses on urban and semi-urban areas of Punjab province and can be used, at least indicatively, for interregional and temporal analyses within the Pakistani context

Investigating the low patterns of modern contraceptive use in Pakistan

This report documents the study “Investigating the Low Patterns of Modern Contraceptive Use in Pakistan” conducted by the Population Council Pakistan in 2014 as part of an extensive research project to determine why use of modern contraceptives in the country remains so low despite large unmet need. The family planning (FP) scenario in Pakistan has changed significantly in recent years, and it is now recognized that the reasons most often cited for unmet need require reappraisal, with qualitative research required for a deeper understanding of the attributes, experiences, reservations, and preferences that women, men, and service providers associate with specific contraceptive methods. Through this qualitative research, in addition to other methodologies, it will be possible to identify and address the real barriers to sustained and increased adoption of modern FP methods in Pakistan. The research comprises four component studies, including: review of relevant academic, program, and policy literature; qualitative study of the perspective of men, women, and service providers on FP; situation analysis of contraceptive quality, supply, and access at health facilities; and examination of contraceptive availability. This report presents the findings of the second component

The effect of traditional birth attendant training on maternal and neonatal care

Objective: To determine whether traditional birth attendants (TBAs) trained via the “SMART Dai” method were superior to untrained TBAs in knowledge and practice regarding maternal and newborn care. Methods: In a cluster-randomized trial in the Dera Ghazi Khan District of Punjab, Pakistan, 120 rural communities each with a population of approximately 5,000 were randomly assigned to a community-based intervention (CBI) or a health systems intervention (HSI). In the CBI communities, 288 TBAs underwent an innovative 8-day training course on maternal and newborn care, initially evaluated by pre- and post-tests. After an average of 19 months post-training, 277 TBAs, together with 257 comparably chosen untrained TBAs from the HSI communities, were tested and interviewed. Patients from both referred and non-referred deliveries were also interviewed. Results: Characteristics of TBAs in the two groups were similar. The TBAs were evaluated according to various measures of knowledge, skill, and practice (including referral), with patient reports on practice compared with TBA reports. By most measures, trained TBAs outperformed untrained ones, often to significant degrees. Conclusion: SMART Dai training seemed to be an important factor in the significant reduction in perinatal mortality in the CBI areas. Properly trained TBAs can substantially contribute to improved delivery outcomes