Financing gaps for Pakistan's contraceptive prevalence goals: Analyses using the Guttmacher adding-it-up methodology.

OBJECTIVES: The objective of the paper is to identify levels of and gaps in family planning financing in Pakistan and to assess whether current funding is sufficient to meet national and FP2030 goals to increase contraceptive use to 60% by 2030. STUDY DESIGN: We estimate the cost of family planning services nationally and by province based on the Essential Services Package and WHO/UNFPA cost by applying the existing Guttmacher global Adding-It-Up methodology. Additional data are also analyzed to assess trends in expenditures on family planning between 2017 and 2021. RESULTS: The estimated cost of family planning services provided in Pakistan in 2017 was US$81 million, equivalent to US$0.38 per capita. The estimated gap in costs to provide contraceptive services to the additional 8.6 million women with unmet need for modern contraception was US$93 million. While we found evidence of an upward trend in overall government expenditure on family planning services over the period 2017-21, the pace of increase was slow and uneven across regions. CONCLUSIONS: The evidence highlights the persistent inadequacy of financing for contraceptive services especially if Pakistan intends to achieve its ambitious national and FP2030 goal of increasing contraceptive prevalence to 60% by 2030. IMPLICATIONS: A doubling of current funding for contraceptive services is required in Pakistan. Additional financing needs to be directed towards the poorest women with unmet need to avoid unintended pregnancies and to improve equity in reproductive health outcomes.

Abortion service provision in South Asia: A comparative study of four countries.

OBJECTIVES: Nationally representative evidence on abortion service provision is scarce in South Asia. To inform improvements in service provision, this paper assesses the availability of facility-based postabortion services in Nepal, India (six states), Bangladesh and Pakistan, and legal abortion services in India and Nepal and Bangladesh (where the official term used is menstrual regulation or MR). STUDY DESIGN: The paper presents comparable indicators on three aspects of abortion service provision from representative surveys of public and private sector facilities, conducted over 2012-2015. Indicators cover three areas: (a) need for abortion-related care (total number of abortions and percent of abortions that are legal and the postabortion treatment rate); (b) availability and accessibility of facility-based abortion-related services (percent of facilities offering only one of the two services, percent which are public and percent located in rural areas); (c) quality of facility-based abortion care (percent of legal abortions using procedures not recommended by WHO and percent of women turned away when seeking abortion or MR services). RESULTS: The proportion of all abortions that are illegal ranges from 58% to almost 78% in the three countries where abortion is permitted under broad criteria. The annual treatment rate for abortion complications ranges from about 4 to 26 per 1000 women ages 15-49 across the countries and states covered. In India and Nepal, less than 40% of public sector facilities that are permitted to provide abortion services do so; in Bangladesh, the situation is somewhat better, at 53% providing MR. Across the six Indian states, 4-43% of facilities that offer abortion care are located in rural areas, disproportionately lower than the proportion of women living in rural areas (49-87%). About 30-60% of facilities offered only postabortion care and did not offer legal services in the three countries where legal services are permitted (with the sole exception of Tamil Nadu where this proportion was only 11%); of the remaining facilities, the large majority offered both services. Medication abortion is offered by the large majority of facilities that provide induced abortion and accounts for 40-45%, of facility-based abortions in Nepal and four of the states of India; in Assam and Bihar, this proportion was much lower (13% and 27% respectively). Invasive procedures that are not recommended by WHO are more widely used in India (up to 25-37% of facility-based abortions are D&C procedures; the large majority of this group are D&C, and a small proportion may be D&E, a WHO-recommended abortion procedure, that could not be separated out in this study because providers use the two labels interchangeably); by comparison, the proportion is much smaller in Nepal (5%). Between 22% to a little over half of facilities turned away some women who would otherwise be eligible for an abortion or MR procedure in Nepal, the six Indian states, and Bangladesh. CONCLUSIONS: There is an urgent need to increase access to abortion, MR and postabortion services, especially for rural women. Greater access to legal abortion/MR services in the three countries that permit these procedures would increase the proportion of abortions that are legal and safe, reduce morbidity and the need for facility-based treatment for complications. Broadening the legal criteria under which abortion is permitted in Pakistan, and implementing access under such broader criteria, is needed to achieve the same improvements in Pakistan. Ensuring that these services are of high quality and comprehensive-meeting WHO-recommended standards-is essential to protect women's reproductive health and rights. IMPLICATIONS: To improve access to abortion, MR and postabortion care in South Asia, all facilities (public and private) permitted to provide these services should do so, and should include medication abortion. Improvements in quality of care are critical: invasive procedures (D&C) should be eliminated through adherence to WHO's standards of safe abortion care and women seeking abortions should not be turned away because of providers' biases.

The constraints of distance and poverty on institutional deliveries in Pakistan: evidence from georeference-linked data.

While institutional deliveries in Pakistan have risen substantially over the last few years, the change has mainly occurred among the wealthy and those with access to services in urban areas. We assess the influence of economic and geographic access to health facilities on institutional deliveries by linking household survey data and georeferenced distance to facilities equipped to provide services for obstetric care in nine districts in Pakistan. Multilevel mixed-effect logistic regression analyses show that the net effect of an increase in distance to a facility by 1 kilometer is to decrease the odds of an institutional delivery by 3 percent. In contrast, household wealth and availability of at least basic emergency care within 10 kilometers substantially increase the odds of an institutional delivery. These effects are more pronounced in rural areas than in urban areas. Disadvantages faced by poor rural women can be minimized by upgrading existing facilities at district and subdistrict levels to provide comprehensive emergency care and by facilitating transportation of poor rural women directly to these facilities when they experience life-threatening complications of childbirth.

Induced abortions and unintended pregnancies in pakistan.

During the past decade, unmet need for family planning has remained high in Pakistan and gains in contraceptive prevalence have been small. Drawing upon data from a 2012 national study on postabortion-care complications and a methodology developed by the Guttmacher Institute for estimating abortion incidence, we estimate that there were 2.2 million abortions in Pakistan in 2012, an annual abortion rate of 50 per 1,000 women. A previous study estimated an abortion rate of 27 per 1,000 women in 2002. After taking into consideration the earlier study's underestimation of abortion incidence, we conclude that the abortion rate has likely increased substantially between 2002 and 2012. Varying contraceptive-use patterns and abortion rates are found among the provinces, with higher abortion rates in Baluchistan and Sindh than in Khyber Pakhtunkhwa and Punjab. This suggests that strategies for coping with the other wise uniformly high unintended pregnancy rates will differ among provinces. The need for an accelerated and fortified family planning program is greater than ever, as is the need to implement strategies to improve the quality and coverage of postabortion services.

Reducing unmet need and unwanted childbearing: evidence from a panel survey in Pakistan.

Pakistan's high unmet need for contraception and low contraceptive prevalence remain a challenge, especially in light of the country's expected contribution to the FP2020 goal of expanding family planning services to an additional 120 million women with unmet need. Analysis of panel data from 14 Pakistani districts suggests that efforts to reduce unmet need should also focus on empowering women who are currently practicing contraception to achieve their own reproductive intentions through continuation of contraceptive use of any method. Providing women with better quality of care and encouraging method switching would bridge the gap that exists when women are between methods and thus would reduce unwanted births. This finding is generalizable to other countries that, like Pakistan, are highly dependent on short-acting modern and traditional methods. The approach of preventing attrition among current contraceptive users would be at least as effective as persuading nonusers to adopt a method for the first time.

Postabortion care in Pakistan.

The current law in Pakistan permits abortion only under narrow circumstances. As a result, women resort to clandestine and unsafe abortion procedures, which often lead to complications. This report summarizes findings from a study that examined the conditions under which women obtain abortion in Pakistan; the incidence, coverage and quality of facility-based postabortion care (PAC); and the extent to which recommended standards for PAC have been implemented in health facilities.

The importance of public sector health facility-level data for monitoring changes in maternal mortality risks among communities: the case of pakistan.

This paper illustrates the importance of monitoring health facility-level information to monitor changes in maternal mortality risks. The annual facility-level maternal mortality ratios (MMRs), complications to live births ratios and case fatality ratios (CFRs) were computed from data recorded during 2007 and 2009 in 31 upgraded public sector health facilities across Pakistan. The facility-level MMR declined by about 18%; both the number of Caesarean sections and the episodes of complications as a percentage of live births increased; and CFR based on Caesarean sections and episodes of complications declined by 29% and 37%, respectively. The observed increases in the proportion of women with complications among those who come to these facilities point to a reduction in the delay in reaching facilities (first and second delays; Thaddeus & Maine, 1994); the decrease in CFRs points to improvements in treating obstetric complications and a reduction in the delay in receiving treatment once at facilities (the third delay). These findings point to a decline in maternal mortality risks among communities served by these facilities. A system of woman-level data collection instituted at health facilities with comprehensive emergency obstetric care is essential to monitor changes in the effects of any reduction in the three delays and any improvement in quality of care or the effectiveness of treating pregnancy-related complications among women reaching these facilities. Such a system of information gathering at these health facilities would also help policymakers and programme mangers to measure and improve the effectiveness of safe-motherhood initiatives and to monitor progress being made toward achieving the fifth Millennium Development Goal.

Social stigma and disclosure about induced abortion: results from an exploratory study.

It is well recognised that unsafe abortions have significant implications for women's physical health; however, women's perceptions and experiences with abortion-related stigma and disclosure about abortion are not well understood. This paper examines the presence and intensity of abortion stigma in five countries, and seeks to understand how stigma is perceived and experienced by women who terminate an unintended pregnancy and influences her subsequent disclosure behaviours. The paper is based upon focus groups and semi-structured in-depth interviews conducted with women and men in Mexico, Nigeria, Pakistan, Peru and the United States (USA) in 2006. The stigma of abortion was perceived similarly in both legally liberal and restrictive settings although it was more evident in countries where abortion is highly restricted. Personal accounts of experienced stigma were limited, although participants cited numerous social consequences of having an abortion. Abortion-related stigma played an important role in disclosure of individual abortion behaviour.

Managing unplanned pregnancies in five countries: perspectives on contraception and abortion decisions.

Why is induced abortion common in environments in which modern contraception is readily available? This study analyses qualitative data collected from focus group discussions and in-depth interviews with women and men from low-income areas in five countries--the United States, Nigeria, Pakistan, Peru and Mexico--to better understand how couples manage their pregnancy risk. Across all settings, women and men rarely weigh the advantages and disadvantages of contraception and abortion before beginning a sexual relationship or engaging in sexual intercourse. Contraception is viewed independently of abortion, and the two are linked only when the former is invoked as a preferred means to avoiding repeat abortion. For women, contraceptive methods are viewed as suspect because of perceived side effects, while abortion experience, often at significant personal risk to them, raises the spectre of social stigma and motivates better practice of contraception. In all settings, male partners figure importantly in pregnancy decisions and management. Although there are inherent study limitations of small sample sizes, the narratives reveal psychosocial barriers to effective contraceptive use and identify nodal points in pregnancy decision-making that can structure future investigations.

Estimating the incidence of abortion in Pakistan.

This study applies an indirect estimation method to develop comprehensive national and provincial estimates of the prevalence of abortion and abortion-related morbidity in Pakistan. Data from a health facilities survey and a health professionals survey from 2002 are analyzed to develop estimates of postabortion hospitalizations and of the abortion rate, abortion ratio, and unwanted pregnancy rate. We estimate that 890,000 induced abortions are performed annually in Pakistan, and estimate an annual abortion rate of 29 per 1,000 women aged 15-49. The abortion rate is found to be higher in provinces where contraceptive use is lower and where unwanted childbearing is higher. The unwanted pregnancy rate is estimated at 77 per 1,000 women, or about 37 percent of all pregnancies. Abortions account for termination of one in seven pregnancies. An estimated 197,000 women are treated annually in public hospitals and private teaching hospitals for induced abortion complications, a number equivalent to an annual rate of 6.4 women hospitalized as a result of unsafe induced abortions per 1,000 women aged 15-49.

Introducing client-centered reproductive health services in a Pakistani setting.

Pakistan is a high-fertility country with elevated levels of maternal mortality and unmet need for family planning. Limited access to and poor quality of reproductive health services and gender-related problems comprise the major explanations for these poor indicators. The authors designed an intervention to address some of these issues and implemented it on a quasi-experimental basis in Bhalwal Tehsil of the Sargodha district of Punjab. The intervention introduced a client-centered approach to providing reproductive health services, including family planning and infant, child, and maternal health care. The intervention consisted of training health-care providers based in fixed-location clinics and in communities. It introduced the concept of SAHR (an acronym for salutation, assessment, help, and reassurance), to inculcate a client-centered approach to care that acknowledges explicitly and addresses a client's gender and power relations within her family and household. Results of the intervention indicate significant effects on providers' behavior related to SAHR elements. The changes provide demonstrable evidence that the public sector can shift toward client-centered services in reproductive health care in a challenging setting.