akistan is the sixth most populous country in the world. It is a low-middle income country where more than 25 percent of the population lives below the poverty line. Thirty-seven percent of Pakistanis live in multidimensional poverty, i.e., lack education, basic infrastructure services and financial assistance. Forty percent of the population is under 15 years of age and 19 percent 15-24 years of age.

Pakistan’s maternal mortality ratio is 186 deaths per 100,000 live births (2021) and the neonatal mortality rate 39 deaths per 1,000 live births. One of the ways of improving maternal mortality and health of women in the reproductive age group is to prevent high-risk cases like high blood pressure and diabetes during pregnancy, unplanned or unwanted pregnancies and unsafe abortions or termination of pregnancies.

Methods of contraception include the use of oral contraceptive pills (combined or mini pill), hormonal implants, injectables (three months), intra uterine devices, condoms, male and female sterilisation methods (vasectomy and tubal ligation), lactational amenorrhea methods, withdrawal method, awareness about fertility days (physiological changes during monthly periods), patches and vaginal rings.

The contraceptives most commonly used in the country include condoms, combined oral contraceptives, intrauterine contraceptive device Copper-T, and 3-month injections containing the female hormone progesterone. Contraceptive pills, injections and implants, if used correctly as advised can be more than 99 percent effective in preventing pregnancy. Appropriate and adequate counselling must be offered at the time of prescribing. Family planning clinics, community-based general physicians and family physicians involved in consultations and prescribing must be trained. Practical guidance on choosing the right contraceptive according to the patient’s age and medical history must be provided to healthcare providers.

A number of women of reproductive age in developing countries want to avoid pregnancy but are not using an effective method of contraception. One of the main reasons is the lack of access to contraceptive services.

It is important that family planning service users are satisfied with the quality of care they receive. This positive experience when they engage with their health system will increase the use of family planning services, especially at the community level. The role of lady health workers in Pakistan is well recognised in maternal and child health, but they lack the confidence and skills to meet their clients’ needs for providing standard and high-quality family planning services. To improve family planning service delivery, competent and confident providers are needed to support clients in meeting their own family planning and reproductive health needs and preferences. A strong health systems approach with an effective training system is required to enhance service delivery. There should be a mechanism for sharing information, expanded access for clients and supervision of trained clinicians.

Lack of availability of modern contraceptives, lack of awareness among women in the reproductive age group, myths and misconceptions about various methods, and the fear of side effects must be dealt with through a robust primary care system led by trained family physicians.

The answer could be a family physician-led primary care system so that LHWs can work under their supervision and they are available for advice whenever needed.

Last but not least, with more than 50 percent population under the age of 25 years, a high population growth rate, high fertility rate and underuse of contraception, measures have to be taken to address the barriers to their use.

Lack of availability of modern contraceptives, lack of awareness among women in the reproductive age group, myths and misconceptions about various methods, and fear of side effects must be dealt with through a robust primary care system led by trained family physicians. Evidence-based recommendations and counselling by trained community-based general practitioners can enhance contraception use. Shared decision-making, in which options are given to patients to choose, increases their adherence to the prescribed contraceptive method. Undergraduate and postgraduate medical curricula focusing on contraception counselling and other learning strategies can strengthen the communication skills of medical students and practising clinicians relating to family planning. Contraceptive services are now part of the essential package of health services (EPHS). Effective contraception counselling and sexually transmitted diseases prevention can also be successfully achieved through other members of primary health care teams like lady health workers (LHWs). Family planning training and certification of LHWs will help deliver effective contraception care.

The health department should ensure the availability of contraception wherever it is needed in primary healthcare centres and community health houses with lady health workers. Strengthening primary health centres, including community dispensaries, private GP clinics and community health workers will improve access to contraceptive information and services. Various methods, including short, and long-acting, permanent, and emergency contraception, should be made available so people can choose what’s best for them.

Connecting communities and health systems will increase community trust and will help them receive the services they need and the quality of care they deserve. Religious leaders, teachers and community support groups can help eliminate the biases and misconceptions that prevent contraceptive use.

Dr Hina Jawaid is an associate professor in family medicine at the University of Health Sciences, Lahore.

Dr Abdul Jalil Khan is an assistant professor in family medicine at Khyber Medical University, Peshawar