Government run family planning services and incidence of RTIs in ...

Government run family planning services and
incidence of RTIs in Pakistan: A case study











Dr. Durre Nayab


Pakistan Institute of Development Economics (PIDE)
Islamabad, Pakistan












XXV International Population Conference of the IUSSP
Tours, France
July 18-23, 2005

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Government run family planning services and incidence of
RTIs in Pakistan: A case study
by
Dr. Durre Nayab

Abstract
Government of Pakistan designed a very ambitious package in 2000 that
emphasised the shift in focus after the ICPD from fertility control towards a more
comprehensive approach, integrating reproductive health with family planning,
and recognised the need to place human beings, rather than human numbers, at
the centre of all population policies and activities. This package however remains
to be implemented in practice, as findings of this paper, dealing mainly with
presence of RTIs, including STIs, also shows. Women accessing government
owned family welfare services for contraception, antenatal care or post-natal care
had higher incidence rates of RTIs. Lack of pre-screening for infections and of
contraceptive choices offered, accompanied by lack of imparting proper
knowledge to users and poor hygiene are among the main sources of these
infections at these centres. Integration, improvement and reorientation of
reproductive health services in the real sense is the need of the hour.


I. Introduction
Pakistans family planning programme “has a long, expensive and generally
unsuccessful history”, concluded Robinson in late 1980s (1987 p: 107), and things
have not changed much even in the new millennium. Starting in 1965, the country
was first in the South Asian region to launch a national family planning programme
but now lags behind its neighbours in all objectives that were part of the country’s
programme. Despite the high level of knowledge of modern contraceptives (95 per
cent), not more than 20 per cent of women in reproductive ages currently use any
modern contraceptive (PRHFPS 2001) and the fertility rate remains at 4.1 children per
woman (FBS 2002). On the contrary, over 40 per cent of women in India and
Bangladesh use modern contraceptives and have on average 3 children per woman
(UNDP 2004). In this backdrop, Pakistan’s population could touch 200 million by
year 2020, from its 151 million in 2004, which in itself is an exponential rise in the
32.5 million population at the time of independence in 1947 (MoPW 2004).

With the exception of Sub-Saharan Africa, interest in reproductive tract infections in
developing countries has developed only in the last few years and efforts are now
being made to establish programmes to deal with reproductive tract infections (RTIs),
including sexually transmitted infections (STIs). Reproductive health as such and
women's reproductive health in particular have been elevated in the agenda of
governments throughout the world partly through the International Conference on
Population and Development (ICPD) in Cairo, 1994, while association of RTIs with
HIV/AIDS has given a further impetus to such attempts. The key components of
reproductive health, as envisaged by the ICPD 1994 and then later by the Fourth
World Conference on Women in Beijing (1995), and the +5 conferences held in 1999
and 2000, include maternal mortality and morbidity, perinatal mortality and
morbidity, abortion and post-abortion care, family planning, reproductive tract
infections including HIV/AIDS, infertility, adolescent reproductive health, female
genital mutilation and gender-based violence. If we look at the information available
on all these facets of reproductive health of Pakistani men and women it does not

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IUSSP: RTIs and Government Run Services in Pakistan
portray a satisfactory picture. The population growth rate still remains around 2%, the
maternal mortality ratio is officially stated to be 340 per 100,000 live births (GOP
2004) and unofficially thought to be much higher, the infant mortality rate still hovers
around 77 per 1000 live births (GOP 2004), attendance for antenatal care is 51% and
the unmet contraceptive need of 33% (NIPS 2001) are just a few glimpses of this
picture. There are certain topics for which no national level surveys have ever been
conducted, including incidence and prevalence of RTIs.

The relation between RTIs and contraceptive technologies is of great implications. It
is a two-way relation as the symptoms of infection may be attributed to the
contraceptive method, affecting its usage, and the whole attitude towards
contraception. Secondly, certain contraceptive methods may increase the risk for
infection or aggravate the infection already present. As stated earlier, modern method
contraception prevalence rate in Pakistan remains a low 20% (NIPS 2001). Fear of
having side effects is a major hurdle to the use of modern contraceptives in Pakistan.
Many women discontinue their use after having suffered an infection or hearing about
a friend or relative with an infection. The PFFPS 1996-97, found that 5.5% of the
urban women had never used contraceptives because of fear of symptoms associated
with such infections. Another study done in two villages of the Punjab province found
that for 41.7% of past users the reason for discontinuation was getting infections,
while 12.8% who never used it had similar fears (Nayab 1998).

The Rawalpindi Reproductive Tract Infection Study 2001-2002 (RRTIS 2001-2002),
on which the present paper is based, found out contraceptive use, especially the use
of intra uterine device (IUD) and tubectomy, to be significantly associated with the
presence of reproductive tract infections1(Nayab 2004). Further analysis of the data
showed government run family planning services to be the primary source of
providing these two methods of contraception, which is IUD and tubectomy, arising
the curiosity to investigate the probable relation between government provided family
planning services and RTIs.

The present study, thus, aims to look into presence of RTIs, including STIs, among
women attending government run hospitals, mother and child centres (MCHs) and
Family Welfare Centres (FWCs)- a change in name in the post-ICPD period from
“Family Planning Centres”. Services offered by these outlets include, antenatal and
postnatal care, contraceptive advice and supply, and child health. Similarly, RTIs
having consequences ranging from less serious to fatal outcomes for the materno-
foetal health, such as, premature delivery, low birth weight, still births, congenital
syphilis, neo-natal conjunctivitis, neurological and cardiovascular diseases, PID and
infertility, are intertwined with safe motherhood, family planning and child survival.
Thus, the functions of government run family planning services coincide with the
consequences a woman might suffer in case of having a RTI.

Aseptic condition during a surgical procedure or a medical intervention can also be a
source of iatrogenic transmission of RTIs. Given the often unhygienic conditions that
prevail at health delivery outlets in the country, including the government run
services, there is a need to look into the presence of infections among women who

1 See Annex-I for a logistic regression models for the factors affecting the likelihood of having an RTI
etiologically among women in the study. It shows having tubectomy and use of IUD to be strongly
associated with having an RTI compared to those not using any contraceptive.
2

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IUSSP: RTIs and Government Run Services in Pakistan
have gone through any such procedure. All this depends not only on the
infrastructural facilities available at the service outlet but also on the knowledge and
ability of health professionals.

In the light of discussion above, the present paper has the following objectives:
1. To look into the presence or otherwise of RTIs among women using different
contraceptive methods by source of obtaining the method.
2. To probe the presence of RTIs among women who have gone through any
surgical procedure on a reproductive organ by the place of performing the
surgery.
3. To investigate the presence of RTIs among women receiving antenatal care by
place of getting the care.
4. Knowledge level and medical practices of health professionals, at different
health delivery outlets, regarding factors associated with reproductive tract
infections.

The present paper is divided into five sections. After this section, which is section
one, that gives the introduction to the topic, section two deals with a brief description
of the government’s reproductive health policies and family planning services.
Section three gives account of the data sources used in this paper, while section four
presents the results along with discussion on the findings. The final section presents
conclusions of this study and gives certain recommendation to alleviate the health,
especially the reproductive health of women in the country.

II. Reproductive Health Policy and Delivery Services
The country’s reproductive health policy emphasises the shift in focus after the ICPD
from fertility control towards a more comprehensive and intersectoral approach
integrating reproductive health with family planning and addressing a wider range of
concerns especially economic status, education, health and gender equality and equity
(GOP 2000). It also recognises the need to place human beings, rather than human
numbers, at the centre of all population policies and activities. A very ambitious
Reproductive Health Services Package was designed in 2000, entailing the following
measures:
• Comprehensive family planning services for females and males
• Maternal health care including safe motherhood, and pre and post abortion
care for complications
• Infant Health Care
• Management of reproductive health related problems in adolescents
• Prevention and management of RTIs/STDs and HIV/AIDS
• Management of infertility
• Detection of breast and cervical cancer
• Management of reproductive health issues of men
(GOP 2000)

This Package however, though approved, remains to be implemented in practice even
in year 2005. The Government admits its lack of knowledge regarding the magnitude
of RTI prevalence, and the problems related to them (GOP 2001), but the practical
focus still remains on family planning. This is evident from the main objectives of the
National Health Policy 2001. It states, “The current Population Welfare Programme
aims at reducing growth rate from 2.4% to 1.9%, TFR from 5.2 to 4.2, and to increase
3

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IUSSP: RTIs and Government Run Services in Pakistan
CPR from 24.4% to 40.3%” (GOP 2001). With such a formulation it is quite
improbable that RTIs will get much attention at the governmental level. The problem
is compounded by too many policies, programmes, strategies, interventions and
targets set forth by government and its various ministries leading to lack of continuity
in any policy and at times creating confusion over the roles and functions of different
personnel and organisations. Examples in this regard are the Reproductive Health
Services Package 2000, Population Policy 2002, Population Sector Perspective Plan
2002-2012, proposal for de-federalisation of population planning programme in July
2002, Population Welfare Ten Year Perspective Development Plan 2001-2011, and
proposals for reproductive health and family planning in the light of the Millennium
Development Goals (MDGs), all of which came one after another. All these plans and
proposals emphasise improved curriculum and training, IEC campaign, maternal and
child health, family planning, and involvement of males (GOP 2004). But the way this
vision is to be implemented differs in these plans and each sets “targets” different
from the other. Some of these “targets” set by the Government of Punjab include
decreasing the population growth rate from 2.17 to 1.6 per cent by the year 2011, and
to increase the contraceptive prevalence rate (CPR) from 30 per cent in 2001 to 53 per
cent in 2011 (GOP 2005). Setting targets in no way humanises the implementation of
population “welfare” policies.

At present, implementation of the population policy, which professes to include not
just population planning but also population welfare, is being carried out by a battery
of personnel/institutional setups with different titles but having primarily similar or
overlapping roles. These include:
1. Basic health units (BHUs)
2. Family welfare centres (FWCs)
3. Lady health workers (LHWs)
4. Mother and child health centres (MCH)
5. Mobile service units (MSUs)
6. National health workers (NHWs)
7. Rural health centres (RHCs)
8. Reproductive health service units (RHSUs)
9. Village based family planning workers (VBFPWs)

Pakistan’s public expenditure on health (as % of GDP) is a mere 0.9% (GOP 2004),
and the stated objective of the latest National Health Policy of “Health for All” (GOP
2001) seems like a distant possibility. The policy accords priority to the primary and
secondary tiers of the health sector to take the pressure off the already stressed tertiary
level. Family planning centres are a part of healthcare system at every level. However,
at the lower level hospitals, there are shortcomings in emergency care, surgical
services, laboratory facilities and at times even qualified practitioners as absenteeism
is common due to a general lack of monitoring and accountability. Women with RTIs
can go to hospitals/health services at any of these levels but it is usually at the tertiary
level they can get any proper treatment.


III. Data source
The paper is based on primary data collected from 508 women in Rawalpindi city, a
major urban area of Pakistan, in 2001-2002, called the Rawalpindi Reproductive Tract
4

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IUSSP: RTIs and Government Run Services in Pakistan
Infection Study 2001-2002 (RRTIS 2001-2002) 2. A representative sample was drawn
for the study using the primary sampling units (PSUs) of the Federal Bureau of
Statistics (FBS) having women from all economic strata, as it was premised that with
income differences come differences in other facets of a person’s life. The study
sample comprised of currently married women aged 15-49 years, having their
husbands living with them. The median age of marriage in urban areas of Pakistan is
still 19 years (PRHFS 2001), so inclusion of young females aged 15-19 years was a
logical choice. Being currently married was of importance because if women were not
in a current union they were unlikely to be sexually active or using contraceptives,
which were factors of interest to this study. Similar reasons led to the decision to
include only those women whose husbands were living with them.

For a holistic approach to the problem under study three basic tools were used for the
collection of data. These were: conducting a questionnaire; having a clinical
examination which was based on the Syndromic Approach3; and finally to have a
laboratory diagnosis to ascertain the presence or otherwise of any infection. The
questionnaire asked women about their: socio-economic characteristics; obstetric,
gynaecological and contraceptive history; hygiene practices; experiences regarding
RTIs; health seeking behaviour in case of experiencing RTI associated symptoms; and
their autonomy status. RTIs included in the study and the assays used for ascertaining
their presence or otherwise among women in the study are presented in Annex-II.

Out of the 508 women who were interviewed in full, 311 (62 per cent of the total
sample) gave their consent for the medical part of the study. The total sample and the
medical sub-sample were very similar apart from a 10 per cent over-representation of
women from the poor economic strata and those who reported experiencing more
symptoms associated with RTIs. The present paper mainly deals with the analysis of
the medical sub-sample as laboratory results are considered a more accurate
representation of reality regarding presence or absence of RTIs among women.


IV. Results

1. Place of obtaining contraceptives and RTIs
In the present study, the CPR was 48.2 per cent, with 38 per cent of these using
modern methods (see Annex III). RTIs were found to be higher among contraceptive
users than non-users, especially those using IUDs (54 per cent) and the ones who
were tubectomised (39 per cent). Women using IUDs were more than three times
likely to have a RTI, followed by those who were tubectomised compared to non-
users (see Annex-I). Those using condoms, injections or traditional methods of
rhythm or withdrawal had likelihood lower than that of non-users (Annex-I). This
trend is consistent with the findings of other studies in the region that found IUD
users and sterilised women having higher rates of infection (Hawkes, et al., 2002;

2 The paper is part of a larger study conducted for the doctoral thesis at the Demography Program,
Australian National University, on knowledge and perceptions of women regarding RTIs; self-reported
and medically diagnosed incidence of RTIs among women and comparison between the two; and
process of health seeking by women who reported having any symptom associated with RTIs.

3 Syndromic approach is based on identification of syndromes, which are a combination of symptoms,
reported by the client, and signs, observed during clinical diagnosis, following the algorithms given by
the WHO.
5

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IUSSP: RTIs and Government Run Services in Pakistan
Wasserheit, et al, 1989; Shrikhande, et al., 1998). IUD use has long been linked to
infections (Guerreiro, et al., 1998; Grimes, 1987; Farley, et al., 1992; Paavonen and
Vesterinen 1980; Soderberg and Lindgren 1981), and findings of the present study
also show that women using IUDs have an infection rate much higher than other
method users or non-users.

Table 1 shows the source of getting different methods by contracepting women in the
sample. The more permanent methods of IUD and tubectomy are the two preferred
methods at the government level in Pakistan, and the delivery outlets are still given
some “targets” to achieve every year in dispensing these methods. This is reflected in
Table 1 as well where government run hospitals and MCH/FWCs are the main
sources of inserting IUDs and performing tubectomies.


Table 1: Place of obtaining the used contraceptive

Method
Source of contraceptive (%) ***
Cases
t

i
c



e
n

g
l

d

m
t
e

WC
i
t
al
/
c
l
i
n
i
a
e
t
i
n
i
c
e
s

an
al
r
n
p
k
/
F
s
b
ot
os
r
i
va
i
t
al
oc
S
H
ar
u
T
ove
h
P
p
s
e
r
v
C
m
H
G
os
h
M
Pills
9.5
4.8
81.0
4.8
0.0
100.0
21
IUD
36.8
31.6
10.5
21.1
0.0
100.0
38
Injections
0.0
0.0
93.3
6.7
0.0
100.0
15
Condom
8.2
6.8
41.1
11.0
32.9
100.0
73
Tubectomy
50.0
36.0
0.0
14.0
0.0
100.0
50








Total
23.9
18.3
33.0
12.7
12.2
100.0
197
(N)
(47)
(36)
(65)
(25)
(24)
(197)
Source: RRTIS 2001-2002.
Note: 1. Excludes 51 contracepting women using traditional methods of rhythm and withdrawal.
2. Chi-square/Fisher’s Exact test significance levels: *** p<.001, **p<.01, and * p<.05.

Condoms that can not only provide protection against pregnancy, if used properly, but
also against transmission of infections were mainly obtained from social marketing
services or bought directly from shops and general stores (by husbands). Evidence
suggests that the social marketing services in Pakistan, like Key Marketing and Green
Star, have contributed in raising awareness and use of condoms in the country
(Hennink and Clement 2004). Use of pills, injections and condoms are the methods
promoted by these marketing services. Husbands buying condoms directly from the
shops can have its downsides if they do not already know the proper use of the
method, as the method is sold without any counselling.

Taking the prospective users’ medical and reproductive histories is important for an
informed and medically sound decision regarding the type of method recommended.
As Table 2 shows, around one third women were using contraceptives without any
medical/reproductive history being taken. Prominent among these are women
approaching MCH/FWCs and those whose husbands buy condoms directly from
shops. Buying from shops/stores could be acceptable in case of continuing use but not
6

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IUSSP: RTIs and Government Run Services in Pakistan
for first time users. Governments run hospitals fare better than the MCH/FWCs but
lag behind private hospitals/clinics and social marketing services in taking
reproductive history before recommending use of any particular contraceptive
(see Table 2).


Table 2: Recording of reproductive history and conducting a pelvic exam at the
time of suggesting/obtaining contraceptive
(%)

Source of contraceptive ***

t

Cases
i
c



e
n

g
l

d

m
t
e

WC
i
t
al
/
c
l
i
n
i
a
e
t
i
n
i
c
e
s

an

al
r
n
p
k
/
F
s
b
ot
os
r
i
va
i
t
al
oc
S
H
ar
u
T
ove
h
P
p
s
e
r
v
C
m
H
G
os
h
M
Taking of reproductive history ***
Yes
74.5
88.9
86.2
16.0
0.0
64.5
127
No
25.5
11.1
13.8
84.0
100.0
35.5
70








Total
100.0
100.0
100.0
100.0
100.0
100.0
197
(N)
(47)
(36)
(65)
(25)
(24)
(197)
Pelvic exam conducted ***
Yes
59.6
72.2
13.8
0.0
0.0
32.0
63
No
40.4
27.8
86.2
100.0
100.0
68.0
134








Total
100.0
100.0
100.0
100.0
100.0
100.0
197
(N)
(47)
(36)
(65)
(25)
(24)
(197)
Source: RRTIS 2001-2002.
Note: 1. Excludes 51 contracepting women using traditional methods of rhythm and withdrawal.
2. Chi-square/Fisher’s Exact test significance levels: *** p<.001, **p<.01, and * p<.05.

Ideally, pelvic examination should be taken before recommending any contraceptive.
The situation at the study site presents a contrary picture as less than third of the
women went through a pelvic exam before recommended using a certain method
(Table 2). The low percentage of conducting pelvic examinations even at the social
marketing service centres hints toward a belief that pelvic exams are not needed when
using methods like condoms, injections or pills. But the low and absent proportion of
women having pelvic exam in government run hospitals and MCH/FWCs,
respectively, is a source of grave concern as these are the sources that promote the
use of IUD and tubectomy as contraceptive methods.

Despite all the talk about “population welfare”, the practical focus still remains on
family planning and target achievement. As findings of this study showed, women
attending government run family planning services were not offered much choice in
the selection of contraceptive method, nor were they informed about any possible side
effects and the proper way of using any method. For instance, women were at times
even coerced to use IUDs but they were neither screened before insertion nor were
told that they have to get it removed after a specific time period, factors that could
lead to getting an infection or aggravating an infection if they already have one.

7

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IUSSP: RTIs and Government Run Services in Pakistan
If we look at the etiological presence of a RTI among contracepting women, we find
that women whose sources of contraceptives are government run MCH/FWCs (53 per
cent) and hospitals (43 per cent) have the highest rate of infection (Table 3). These are
the two sources where IUD and tubectomy are the main recommended means of
contraception, the two methods that are prone to have higher infections rates if not
carried out under specific conditions and following strict procedures.


Table 3: Has any RTI etiologically by source of obtaining contraceptive

Has an
Source of contraceptive **
Cases
infection
t

i
c



e
n

g
l

d

m
t
e

WC
i
t
al
/
c
l
i
n
i
a
e
t
i
n
i
c
e
s

an
al
r
n
p
k
/
F
s
b
ot
os
r
i
va
i
t
al
oc
S
H
ar
u
T
ove
h
P
p
s
e
r
v
C
m
H
G
os
h
M
Yes
43.2
16.7
14.3
52.9
8.3
27.8
35
No
56.8
83.3
85.7
47.1
91.7
72.2
91








Total
100.0
100.0
100.0
100.0
100.0
100.0
126
(N)
(37)
(18)
(42)
(17)
(12)
(126)
Source: RRTIS 2001-2002.
Note: 1. Excludes 71 women from Table 1 and 2 who refused having a medical examination.
2. Chi-square/Fisher’s Exact test significance levels: *** p<.001, **p<.01, and * p<.05.


It would be of interest to see the presence or otherwise of any RTI among women
using different contraceptive methods by source of obtaining it. As can be seen from
Table 4, government run FWC/MCHs (53 per cent) followed by state hospitals (43
per cent) have the highest rate of infection among contraceptive users. Private
hospitals (17 per cent) and social marketing services (14 per cent) have a rate much
lower than government run services (Table 4). As stated earlier, IUD users (54 per
cent) and those having a tubectomy (39 per cent) have a higher rate of having a RTI,
as can be seen in Table 4. Condom users in this study have the lowest rate of infection
(9 per cent), hinting yet again the usefulness of condom use as a prophylactic against
pregnancy as well as infections.

Certain contraceptive methods, like IUD and tubectomy, can make women more
susceptible to having RTIs (Population Council 2001, Cates and Stone 1992), but as
Table 4 shows the higher infection rate in government run services is not only because
IUD and tubectomy are the two preferred methods there. IUD users from government
hospitals had a much higher infection rate (80 per cent) than the IUD users at private
hospitals/clinics (40 per cent) and social marketing services (25 per cent). A similar
trend is found for women who were tubectomised (Table 4), with women getting the
procedure done at government run MCH/FWCs having a much higher rate of
infection (86 per cent) than the private hospitals/clinics (11 per cent). This trend is too
consistent to be attributed only to the nature of contraceptive and the resulting
increased susceptibility of women due to a particular method. The higher rates of
infection at government run facilities indicate that the system is lacking in conditions
that could guarantee safe adoption of family planning methods.
8

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IUSSP: RTIs and Government Run Services in Pakistan
Table 4: Etiological presence of RTI with the source and
nature of used contraceptive

Source
Proportion having a RTI etiologically by
Cases
respective contraceptive (%)
having
RTI


y

m

D
om
al
i
l
l
s

d
P
I
U
ot
j
e
c
t
i
on
e
c
t
o
on
b
T
I
n
C
u
T
Government hospital
50.0
80.0
-
0.0
35.0
43.2
16
Private hospitals/clinic
-
40.0
-
0.0
11.1
16.7
3
Social marketing services
18.2
25.0
0.0
15.8
0.0
14.3
6
MCH/FWC
-
50.0
100.0
0.0
85.7
52.9
9
Husband
-
-
-
8.3
-
8.3
1








Total
23.1
54.2
11.1
9.1
38.9
27.8
35
(N having RTI)
(3)
(13)
(1)
(4)
(14)
(35)
Source: RRTIS 2001-2002.
Note: Including only women who tested positive for a RTI in Table 3.


2. Place of having an operation on reproductive organ and RTIs
Iatrogenic factors can be a major source of infection during and after any surgery.
Women in the present study were asked if they had gone through any operative
procedure on their reproductive organs. Kind of surgeries reported by women include,
induced abortion, dilation and curettage, caesarean delivery, removal of cyst in the
uterus and removing of blockage in fallopian tubes. Taking into account women who
had any of these surgeries, in two years preceding the survey as the cut off point, we
find government hospitals to be the main source of getting these surgeries done,
followed by private hospitals/clinics (Table 5).


Table 5: Presence of RTIs among women having an operation on reproductive
organ by place of surgery in two years preceding the survey

Place of surgery
Has an infection etiologically (%)
Cases
Yes
No
Total
Government hospital
35.3
64.7
100.0
34
Private hospital/clinic
15.4
84.6
100.0
13
At home
66.7
33.3
100.0
3
MCH
25.0
75.0
100.0
4





Total
100.0
100.0
100.0
54
(N)
(17)
(37)
(54)
Source: RRTIS 2001-2002.
Note: Including only women who had a surgery in two years preceding the survey and also consented
for the medical examination to ascertain the presence of RTIs.

Although small in number, women having a surgery at home had the highest
proportion having an infection. Such surgeries are often performed by ill-trained
professionals or traditional birth attendants (dai) under unhygienic conditions so it is
9

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